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R. P. ROWLANDS, M.S.Lond., F.R.C.S.Eng. 

Surgeon to Guy's Hospital ; Lecturer on Anatomy 
to the Medical School 


PHILIP TURNER, B.Sc, M.S.Lond., F.R.C.S.Eng. 

Surgeon to Gny's Hospital ; Teacher of Operative 
Snrgery to the Medical School 

Vattb 191 3llu0tc.ttion0 (40 tn Colour) 




Prmltd /« fir.ot BrilaiH 


Thi8 book, uf which five previotw etlitiutitt buve uppeured, was tbo 
oatoome of a stmng belief which Mr. Jarobson held for many yeani, 

that a work on <i|H'iativc suip-i v wliich uimt'tl at beiii<r iimro rnniprt'lu'ii- 
>i\\f in Hcopf and fiillt-r in detail than those already |iu1)lislied. would be 
of service to many who had icMi nlly hvt'n apiiointed to liosjiital stalTs, 
and to those who were working; lor the higher examinations. For thcHe 
this bouk is specially intended, and, as the authors have {xiinted out 
here aud there, some of the reconuneudatiuits made i'|)|<ly to those wh(t 
have not a well-appointed i>ospital staff at their back. 

l ime and space set a lin.ii to the operations whieh can tie deaeribed. 
Ihercfore preference is j;iven to those we hav .niind mo^*' iMteful. 

In the s[)eciai departments of sii'u'ery si' i as tlinw ..i thi' ' ear 
and throat, gyna;(<>lof;y and orthopatlics. .uly the im}«*trtant well- 
established oiK'ratioiis wliieh a general surgeon can safely pei, . ui are 
considered here, uud no attempt is made to compete with i!»'irt**e8 on 
these special subjects. 

In this 'dition we have endeavoured to save spat'e and umi' !!• - 
repetition l)y devoting sjH'cial ehapteis to " the exaiiiinai !nn. p 
and after-treatment of the patient. " 

The whole book has been carefully revised and a great d al . is 
been entirely rewritten ; this applies especially to the secti' ou 
Abdominal Surgery, and the chapters on the Surgery of the kf A- 
Vessels, and of the Brain. Ear, Nose and Throat. 

We are well aware that the hook will, from time to time, i-ij^,. -« 
much alteration. '1 his is uuavoidalile in a subject so progressiv.^ a 
changeful a- iiaxlern surgery ; it is especially unavoiilable when a 
desires to do full justice to the work th)nc by the crowd of laboun i 
engaged in the same field at the present time. Many of the method 
sttffiested in these pages will, later on, be rejected, but it is only by 
submitting novelties and suggestions to the one true test, that of time, 
that we shall know liow many are really worthy to 8urvi\'e. If this 
book aids in bringing about the application of this test, it will not have 
failed, altogether, in its purpose. 

The plan of the ])()ok, witli whii li some judges found fault, remains 
unchanged. Mr. Jacobsou adopted the division by regions deliberately, 
desiring that those for whom the book is intended should study the 
anatomy of each region at the same time as the account of the operations. 
In this edition it has been found convenient to insert the section on the 
Leg in the first volume, so that the increasing claims of abdominal 
BUi^ery could be adequately met in the second volume. 

To our great regret Mr. Jacobson has been unable to continue the 
laburiooa and brilliant work which buUt up this book and nuuntained 



its «,vat ivi.utati.m f-r so nmnv y«l«. Mr. j^'ip j'''-* 
hnns.-H ...,(. . Iv r. s,H.ns,l,l,. lor tV «itHo,« rtc H.g with ^" .«- > 
,he H.a.l a,urN...k, Mm st an.l r,.,H., Kxtr-nufy. Mr. i. »•""»;";" 
Smith, Smior I'hysi. iai. an.l Cynaroloni.t to Guy » 
hlH apiin thoroughly .. vis..! a.ul I .rp lv .. w„t». n the ch«pt«» «i«»lii>g 
with the operatioM on the Ovury uimI I t. rus. 

Many iiew wd original illustration, have u.UI.U, unU .h sn. 
to .xpn^ our grufful a.knowU.lgmont. to >\at...n ( ';•;> 
l'..a...- (iouia.Mr Vut.>rH...sKx,sir Arbuthtmt LaiKs ^^^^ 
Sir Honrv Monis. Sir li. ik.l. v M-ynihan. Sir M. c1uir rhouMwn. 

8«,p80uHaiall.v..lo.u.tlun.|l»t.lnn.soM.Mr nun. M.I.-.Paul H^^ 

Hal8tra.l, K.-llv, K.K h.r, C H. Mayo. W. J. >»"y<'' I i' 
yui.uki-. S.iul.l.r. T.ittU-, Young an« .rthm: al«» to /A- •«""''^-^ 
Sun,.r„,\iud u. k.w.Nvl...ln,>u'..tH an- nl«. nmdc to iwm.e wl.o ''"v.; .a«m. 

Wheelhou-e. It .v.nal..s for us to;.- v.-ry >!ratrfullv the 
encoorMenH'i.t givw. hv th.- n-vi.'Ns.Ms ot ,.n'VUMis .■■htu.ns. aixl a host 
T^a^^udJu froui all parts of .h. xsorl.l. NW o,.lv ^ that t . s 
edition mVv- deserve some of the things wntt.-i. of its ,,,v,l..j .^.-ots. 
an.l that ii will !»• found t.. give pr.H.f ol the t%v.. nia..j ol.J.'.-ts whu h v . 
hive tn..l to kooj, before iw-to do justice to the work ..I o lu .s an. l o 
save our r. adem some of the dimcultie. and anxieties whah have U-sct 
our paths. 




I Frkunikxry (*<»-«ii>kr.»th>!«s.— K««mii»tion siul pri'iiitrutiun 

o( thP p:i)i'Mit ......... I 

r 'nki spiN. Traiisfii>M>ii. Skin iirnfliiiK ..... M 

111 IMK (iKNKRM. l'l>|XTH WITH KKl. \K|I Tl> .\MI'1 T.\ IlllNS, TMK 

LitMTi RK iir .Xrtrkibii, asd thk Hi wjmiv or Bi«oo-vftwKi4» 

\M> I.VMI'll \TII S ........ 40 

IV. ( ll'i.ii VTinvs i)N TiiK II \M>. A 111 |Mit .it imi iif lliiuir-. Ampul. I 

tioll 111 Ihc tlllllllli. I',llli:ll rsrisinll iif till- tlllllllli. K\rl~hiM 

of till- ImuriN. ( 'iiiisci viitiv<' Hiirurrv (if Ihi' liiiiiil. Uciiiiiiiii nf 

scvcnil ilij{ilr<. Sii|icriniim'r.irv ditfits. Wct'licd litijicrv 

( ontriictcfl p.iliiiiir 'iiHi i^i. ( ■iinuciiilnl mid other ciintractioim 

of the tinners. Ni-f'dlcM in tlir li:iii<l. I'liiimr h.i'niorrhnnr. - 

CnmpoHiHl iKkliiiitr ganglion. 'I'ulicn'ulouit teno-«jnovitw. — 

J'almar anpurynni. — DfierationH for t he union of diviiin i tcmdonii. 

--Ti-norraphy.— Tcno|>liu»t.v. — Tcmlon tranMpluiititlion cxpp- 

ciiilly In Hnf ion to itHotiinloympnt in infantile paraly.nis . . 57 

V. Opkrvtiuns ii\ IMK \Vi;isT.- Kxci ion of tlie wri-'t-joint — 
O|x>riition in mul-unitiHl ('ollex M fracture and M'|Nirullon of the 
lower rpiphyf*iH of the radiun.— Amputation through the wrist- 
joint. I.igatniv of the radial aitery nt fill' tin'k of the wrist III 

VI. Ol'KUVTloNs (IS TiiK I'(ii:k\rm. LiLMtiin' ' f tlic radi:il artery in 
the forciriii. I,i;.'atiir'e of the ninar arli iy in tlie forcariii. 
Partial excision of the radius or ulna.- l)|»erative treatment of 
Volkiuann o contraction. — Amputation through the forparm . li!tt 

VII. (>l'Kll\T!ilNS IN TIIK N KlUlinor RMl II li> UK llli: Kl.Hi iW-.IIll ST. ■ 

.Viupiitation through the ellHiw-joiiit.- Kxcision of the elbow- 
joint. Krasion of the elliow-joinl. Operation for fracture of 
the olecranon. — Operations for fnictim' of the condyles of the 
humenw and for separation of the lower epiphysis of the 
humenB.— Venesection. — IJgaturo of, the brachial arteiy at 
the bend of the elbow ....... 142 

VIII. ()PFR.\TIosg ON THK Arm. Ligature of the brachial artery. 

Amputation through the arm. — E.xcision in contiiuiity of the 
shaft of the humerus.— Bone grafting.—Oppmtiom on the 

musculo-spiral nerve • • 171 





till- axillary iiiti<r\-.— Aniputatioa at the shoiililiT-joint.— 
Kxcisiou . ' the dhouWer-joint.— Ounshot injurien of the 



XI. Removal op the Uppkb Extrewitv, Arm, Scappla, and 
GREATER PART OF THE Ci.AVicLK.— Intewcttpulo-thoraoic am- 

XII. Operations OS THE Ci.mcLE. — Removal of the clavicle . 


XIII Operations on the Scau.— Fibro-celliilar growths, molluncum 
tibrosum, or p-vhydermatocele of the scalp.— Aneurjsiu by 
anastomosiM. —Operative interference in growth of the cranial 
lionos and dura m iti-r 

XIV. TREPHlNlNr..— Operative interference immediate (ir later in 
fractures of the skull. — ^Trephining in fraetunnl sUiill. 'I'rcpliin- 
ing for pus between the skull and dura mater. — Trephining for 
middle meningeal hiemorrhage. — Trephining and exploration 
of cerebral abscess due to injury - Trcj>liiniiig fci ppilcpiy and 
other later results of a cranial injiiiy. (>iKTati e interference 
in the case of foreign iiodies in the brain ..... 

XV. Cebebbai, Locausation in RKrERENCE to Operations.— Of era* 

tioM for tumour of the brain.— Practical value of cerebral locali- 
nation. — Questions arising before operation on a cerebral growth. 
- Oprative procedures on the brain, chiefly for the removal 
or tlio i)alliative treatment of yiuwtlis. ( raiiiectoiiiy for 
iiiieioeiplialus, idioey, \c. 'rrei)liiiiiii<z in mneial i)aralysis 
of llie insane, and in other forms of insanity. Operative tivat- 
iiient of liydro<cphalus — Drainage of the ventricles 

XVI. Operations on the Ear. — The radical mastoid operation. — 

.Abscess in the brain. — Meningitis.- Operation for otitis media 

XVII. Operations on the Face. — Operations on the fifth nerve. — 
Removal of parotid growths.- Operations on the facial nerve. — 
Stretching the facial ncr\ e.- Oix'iative treatment of intractable 
facial paralysis of ]) origin. — Restoration of Steno'a 
duct. (>i)erative treatmeot of lupus.- Operative treatment of 
rodent nicer. Hernoval of ii.irotid growths. — Practical points 
in the reino\(d of )i.irotiil growths. — Operative treatment of 
na>vi. ()j)pralive methods of treatment . . . . 

XVIII. Excision of the Eyeball 

XIX. Opbrations on the Frontal Sinuses 













.-> '.» 

Operations OF THE Jaws. Kf^ci^ion of the ii|,|;.r i.iv.. pMriinl 
iumI t-ompleto.— Operation.- mi tin- ai'tnim cf II ii:liiii"n-. 
Excision of the lower jaw, partial ami lompU tr. U|K ialinti.i 
for fixity of the lower jaw 

Plastic OrERATToNs r«K Uki'air <'F TiiK NiisK 

OpERATIOSS OS THE XasaI. Koss r. I!c in<i\iil of foiviirii 
bodies.— Turbincctomy.- OperatioiiN U<i (|i l!<i t. il M |itniM. 
Removal of naw»l jwlypi.- OjK'ratioH for iia«> -pluiryiiKfiil 
fibroma and sarcoma - Removal of adenoid* and eiilarjteil 
tonsils . . . ■ ■ 

Ol'EUATlONS ON- THE Lll's. Hiirc-lip and other pl.istir o|htii 
tiwin on the Hps ami face 

Oi KRATioNs ON THE Palate.— Olierations for iloft jialato. 
Kcinoval of growths from the palate 

Removal OF the TosHi'E.—Oiierations for epithelioma of tin- 
tongue . • • • • 

, Ocerations FOR Growths OF THE Tonsii, Faicks has- o;-- 


, OPERAIIOSS ON the \ir-I'ASsac;ks IN TMK Ni:( K. riiv 
rotomy. — Laryngotomy or intcr-c lico tlivrotoiiiy. Tiiichc- 
otomy.— THW-hcotomy with si)et ial it fi ivncp to l ast-s of im iii 
branous laryngitis.— Intubation of the larynx as a siil.-titiitc 
for tracheotomy in membranous larjiigitis or stenosis of the 
larynx.- -Technique of intuliation. -Other in»licatioii> f..i 
tracheotomy.— Kxtni-larjngeal operations for removal of 
growths of the larynx; excision of the larjnx. [virtial or 

Removal OF t'oBEiox IJouiEs from the I i i kr Air i assaoks 


Oi KRATKiNs ON THE Thyroii) tU-ASD.- Kxtirpatiou of part 
of the gland.— Enucleation of encapsuled tumours.- Ligature 

of the thyroid arteries 

Operations fob the Removal of I.ak'm: Dkkt skviku 
Growths is the Neck, Tuberci loi s ( ; la n i >s. I . y m p 1 i a n < ; h < > 
mata, Thyrooujssal and Branchial Cy.sts.— Removal of 
cervical ribs 

Operations on thk (Ksoimlmm s. (Ksophagotomy. - tEso- 
phagoHtomy.— (I-sophagettomy. (Ksophagoal iHiuches 

Operations oh the Spinal essorv. Upper Cervical 
Nerves, asd Sympathetic.— Partial neurectomy, or ner>e- 
stretching.- Resection of the cen icnl sympathetic for exoph- 
thalmic goitre, i^c. 


Ligatureof the tomiwral arti rv. I.i^atuieof the facial arti'i y. 
— Ligature of the occipital artery. Ligature of the lingual 
artery." Ligature of the common carotid. Ligature of the 
external carotid.— Ligature of the internal carotid. Ligature 
of the vertebral artery.— Ligatureof the subclavian in itssecond 
and third parts.— Ligature of the tiivt part of the subclavian.- 
Ligature of the innominate.— Surgical interference hi aneurj sms 
of the innominate and aorta 






< II II'. 

X\.\l\'. KhMDVAl. OF TIIK HrKAST ...... 

XXXV. rABACK.NTKSlS AM> ISt'ISIO.N OF THE t'llKST. — Kllipyelim. — 

Bes«>ctioii of ribn. —Operative interference in injuriei* of the 
chest .......... 

W .WI. Orr.RATio.Ns UN Tin: Li Ni: AM) THK .Mkdia.xtim M 

.\.\.\VII. TAPPiNii or. IscitiiNii THE rERicAr.i>H".M. — Sutiirc of woiuuls 
of th? heart. — Cardiolysis . . ... 






.XX.W'III. .A.\iprTATi()\ AT THE HiP-JoixT.- Kxcisioii of the hip-joint. — 
Operative treatment of hip-diHease.—Operative treatment of 
8acro-iIiac diHease . 805 

-VXXI.X. ( '(iN(iKSTKi) Disi.or.vTiox of the Hip: C'ox.\ V.\ra . 826 


XI, I. .\>iP|-TATloN THRoniH THK Thkih. — Removal of PXostt)si-i. — 

Fi;w liili s uf the fi'iimr ...... 846 

A.MITTATIdX TITHonai llIK KkKK-.KpIVT. Kr.lsiot!, C-Xcision 

and arthrodesis of the joint « iring of fractures nf the ])att'lla. 
— Removal i.f lotwe bodies and detached cartilage 'i from 
the knee-joint ........ 86:' 

XLIII. LiiiATi'RK OF Arteries in the Fopijtkai. .Spack and thi 

I-';'; ......... S'.t4 

Xl..l\. Amputation or iiii; l.ic;. ()|c!ation for Xecrosis.— Com- 
pound fracture. Siiiii>le fracture. — Varicose v<Mn» . . W»o 

XIA'. Ijo.^TUBE OF l>ORSAlJ!< Fedis.— Amputations of the foot.— 
Kxcision and enision of the ankle- joitit. E xcision of t he t>s 
calcia. — ^Tarscctoiiiy ....... '.(.■{(• 

XIA'l. Osteotomv i-ciK .Snkvi.osis ok TiiK Hip-joixT, Coxa V"ara, 

Gf-ni- m, anu (Je.m- \ ari m .... {loJ) 

XIA'IF. Tenotomy am>Tesi>ox LENc-.TiiENlXf:.— Trcafnicnt of seven' 

taliiiis <(C,I 

.\ i I. ( IPKR.vTioNs ON Neuvks.- Suluri , grafting, and anastomosis . 07S 



XLI.X. Spina Bifida. -Laminectoin\ . — 'i ai/iiing tlie spinal theca. — 
Spinal an .sthtisitt.-^Anoci-atsociation .... 











preliminary considerations. ex amina tiow amd 
freparahoh of tbe patient 

Patients ivquiiiiij; siir<.'i( al <)|H'iutivetrcatiiiPnt may roughly be divided 
into two firoups: I. Tliosi' in whom the operation is urp'iitly r(M|uir<>d 
for some injiirv or disease wiiich seriously imperils life. II. Those in 
whom the condition is less urgent, so that there w no immediate necessity 
for the operation. . . , i ■ 

In the first group, cases of acute mtestmal obstruction for mstance, 
the .symptoms ma\ be so grave that prenous exanunation of the patient 
mav be undesirable ; anv risk nmst be taken in the attempt to save life. 

In the latter group iandue haste is not only unnecessary but should 
be avoided ; a careful examination and preparation of tli<' patient should 
alwavs be made before the operation. The iireliniinary e.xannnation will 
freqiientlv enable the surgeon to decide upon the most desirable treat- 
ment, i.e. as to whether, in elderly patients, a palliative or a radical 
operation will give the best prospect of ultimate success ; it will also 
aid the aiiicsthetist in the selection and the administration of the anses- 
thetie. The preliminary preparation, too. will usually play a very 
important part in determining the success of the operation. 

In addition to an examination of the physical condition and the 
functional activity of the chief organs it is also necessary to take into 
consideration the ape. sex. occupation, habits, and temperament of the 
patient, and to make incpiiries as to the existence of any general consti- 
tutional or hereditarv disorder. 

Age. It was fonnerlv thouL'ht that operations were not well borne m 
childhood and in old age. Though t(. a certain extent still true, modern 
methods and precautions have considerably diminished the risk of 
operations at the two extremes of life. Young children are said to 
stand ha>morrhage badly, but as Sir Frederick Treves has pointed out, 
if the relation of the amount of blood lost to the total amount m the 
boilv is considered, voung children are probably not more seriously 
atl'ected than adults. ' Post-operative shock is often excessive in infanta 
and voung children, and is a frcpient cause of death after abdominal and 
other operations which necessitate the manipulation of the intestines 
or other important viscera. On the other hand, children often show 
a remarkable power of recuperation and may recover from an apparently 
desperate condition. Both these points are illustrated by the results 
obtainetl bv the modern method of treating an intussusception by 
laparotomv(</.r.). Ditiiciilties with children often arise from the restless 
character of the patients, which mav make it almost impossible to keep 
the affected part at rest ; displacement of dressings may also occur, 
which is likely to interfere with the healing of the wound. When the 



on the other hii.ul. usually had suhjeets. 

TitP children old peop e do not stand shock well , tney a'^o air 
Heriiislv a«S bv lo's c,f blood and do not diow the rec« 

nrnltTSeKS to.,, that in old people confinen.ent to hed may 
lead "on'esH™ of the base of the lungs and hypostatic pneumonia 

of lon,-contiuued pressu^. on the 
iU-nouLZd skin ^l^v the bony prominences, and will not infrequently 

""Kl^J^^^^^^^^^^^ for an acute condition, seriously threatening 

life LTcapaWe of cure or relief bv surgical interfenMu e. is contra- 
inSic^r.Hl Xv on account of old age/ If a skilled ana^sthetistconsiders 
Sat f ieiuial anaesthetic is not d'Lirable, either spinal anesthesia or 
local ana'sthesia may bo employed. onerative 
The results of prostatectomy show what can be done b> OF^J^^^ 
t Jtment in old men, who apart from their nnnary trouble are often 
verv feeble and whose organs are by no means healthy, 
veryfeebleana g ^. ^^^^ ^^^^^^ f,,^ ^^^gical 

opeS.ns -thT men. This, ho.^ver, is the effect of temperament 
Kr than sex. and the bearing of the former upon operative treatment 

^•'\^^^i;:i ijm women it is always necessary to l^r in nnnd 
the importance of anv unsightly or disfiguring scar, especially "P"" 
expi^S part of the bodv. In a man a scar upon the face can oftenbe 
cJ^etefv concealed bv'the moustache or beard ; m a woman such con- 

'^^^Z:^. .hen planning anv.such operation to ^ 
that the scar is in as inconspicuous a position as PO««|ble^. Th 8 can 
frequentlv be accomplished by making the incision m t^e 'me of wme 
2 al fold or crease in the skin. Accurate appositicm of he edg^ ol 
the incision, early removal of stitches, and primary union of the wounc 
are all of the greatest importance in securing a neat scar. 

Unless ur^itlv called for by some acute trouble, operations n, he 
groin perineum, or abdomen should not be earned out : 
Hon VV th regard to operati.uis in other regions the wish of .the patient 
lould be considered. %lany won.en prefer to have nothing done at 
?h?8 time, but should the patient make no ..b,ect,on n '"irm is like y 
to result OFrations are best avoided during nregnaiu^. espec 11> 
dnn^g the later months. The danger here, of course. ,s tha o.n abortion 
mav follow. The chance of such an accident .8 however slight, and 
not infrenuentlv it will be felt that the risk should be taken. 

Ope»S for »cut« abdominal trouble-, and the removal of ovanan 



cysts, hav« frf(|uoiitlv Ix'pii undortakon in prejinant woiucii without 
any mishap. What has hwn said about prepnancy also to a great f xtont 
applies to operations durinjt lactation. This throws considerable strain 
I on the system and renders it desirable to postpone any operation which 
i.^ not urjiently recjuired. 

Temperament. Hefon* recommemlinj; any serious operation it is 
always well to have .some knowiedjie of the |)atient's temperament and 
to ol)serve his mental attitude towards tlie and the treatment. 
Such information may help one cr)nsi(lerably in the choice of treatment, 
operative or otherwise ; it will also fretjuently have a great influence 
upon the ultimate result. A placid and cheerful state of mind is an 
encouraging sign in a patient who has to face a serious operation. An 
apathetic fatali.stic attitude, in which the patient does not care, or scarcely 
wishes to recover, is on the other hand of very bad omen. Considerable 
care must be e.xerci.sed before recommending operations, unless they are 
very obviously indicated in neurotic subjects. 

A good example of this is seen in the symptoms which are associated 
with a movable kidney. These patients are very often neurotic, and in 
such, even though the kidney by the operation of nephr(»pexy be firmlv 
fixed in its normal position, the sym])toins will prol>al)ly contimie. 
The same operation for similar symptoms in a patient of normal sensi- 
bility and placid temiierament will probably result in their com|)lete 
disappearance. Mentiil worry of any description is a serious di.^advantage 
to any patient who requires operative treatment. Restlessness of mind 
will probably lead to bodily restlessness, and the two combined may 
have a very il! effect. Worry in men is generally due to business matters, 
and in women to their houscho' ' .TfFairs and their children. On this 
account, as well as for conveniei nursing and treatment generallv, 
it is usually ailvisable not to ope in the patient's own hoiiu' but to 
have them removed from familiar surroundings to a hospital or nursing 
institution. Under these circumstances visitors can be limited or if 
necessary totally forbidden, and the worries, which though often trivial 
are very real, can thus be kept from the patient ; it is practically im- 
possible to secure this freedom from mental irritation if the operation 
takes place in the patient's own home. In restless and neurotic patients, 
too. the new surroundings and unaccustomed faces are often of the very 
greatest benefit. 

Habits. The success of an operation may be seriously affected bv the 
patient's habits. Unfortunately these are often unrecognised before the 
operation, for the patient is naturally averse to give information, and if 
the suspicions of the surgeon are aroused the suggestion will probably 
be denied. That the vicious habit is indulged in is thus usuallv revealed 
by disturbances, either mental or physical, after the operation. The fre(juent and important of these habits to be considered is alcoholism. 
An alcoholic is certainly a bad subject for at any rate nuijor operatioiis. 
This is true not only in the case of drunkards but also in that mere 
numerous class of in(li\nduals who, though they would deny e^ er being 
intoxicated, are yet continually taking small doses and are unable to 
do without the drug. The dangers attending operations ujotii alcoholics 
are thn in number: (a) there is the possibility of an attack of de- 
lirium tremens, or of some less serious mental disturbance; (6) the 
normal healing of the wound is likely to be interfered with ; (c) there 
may be serious general complications. 



Delirium tremens mav appear for the first time in an alcoholic subject 

♦ w. tn .l onention When operatiiifr „n an alcohohc sub ect it is 
s e 1 p^^^^ conrpletely^.f the drug, but to allow small 

Sar Jos:-s of stimulant. Post-op-rative delirium tremens is always a 

-^StSi^M.;; or:l,::a' h^r imdouhtedlv a deletejo. 

nth i readily and are (^.ercome with greater diffaculty than 

'""SlS-^^iel. liable, for mnch the same reasons, to a m.mber of 
grave vKral troubles, such as pneumonia. < ''"^^^lon o tae heart, 
f^ronic nephritis, while gastric dUturbances of ; 
are also exceedingly common. These may ^PP^^'^J. '^^^'''^t, ! ; ' 

esent are likelv to be accentuated by. an operation. These troubl. .s 
i , aecmi.panied l.v .lelirinm tremens. All these complica ions an 
isp^dal Iv ke V to appear in hard drinkers after severe operations ^,r 
Susacu e injuries an\l .liseases. It will thus be >,.en tha a consulerable 
i to be expected after such operations on these patients. 
s"t^ pSblv give much'trouble to the 
Thev mav be expected to take large quantities of et lu-r or chloroform 
the St ^ e of excH^ation is much prolonged, and t is difficult, and imhM^d 
son leases almost impossible, to secure complete muscular relaxatiom 
WhaJ h^ been said of alcohol is to a great extent true o the subjects 
of othe dr^' habits such as morphia and cocaine. The sudden depnva- 
i;^!;;;;: ;^:;;; likely to upsetn,oth the --tahn.. p vsica f^^^^^^^^^^ 
of the bodv On this account the patient should m all th. s. cast s m 
still allowed' reduced quantities of the drug to whu h he is accustormjcl 
F"ve smoking mly lead to troubles in a-jh; -"^ ''f J - 
though less .severe character to those seen m alcoholics. Such • pa 'J 
nav often with advantage be allowed to smoke occasiona ly a few daxs 
LfSr the ope tio ,. pr.n ided of course that the disease or mjury was not 
fn the^Xoi the mouth, respiratory passages, or other situation where 

"^r^^^Z^f^^^i^u general constitutional conditions which 

-h patients a,. 

bad sub eels f or nearlv all operations, 'fhis is due to a variety of causes. 
The^Sve a ep.^^ t of fit mav be the result of continu^ excess in 
Ltg S drinking, which of itself is a -rious matter The exc^^^^ o 
fat in the subcutaneous tissues may be assoc.a e.l ^^'\ -\;^ >. Nation 
the mesentery and the omentum, while fatty liver and fatt^s inhltraticni 
i dege erat^^^^^ the heart are also likely to be present, '^-h P^^^^^^^^ 

av be unable to breathe satisfactorily unless well propped up in bed 
'a posSon Inch their weight may render it ^^^f^'^^^^^^^'^^l^ 
administrai ..nof the anaesthetic will, on account of the fatty viscera, 

SeTio;:^ « and dangerous. Their "-S^S^^^^^^ 
quent nuising and after-treatment very difficult. The skm itseu m 


often unhealthy, eczema may ho attually prosciit. or readily appear 
in natural folds or clefts such as the jtroin. the axilla, the unibilici», or 
in women, beneath the breasts. Satisfnctory cleatisinj' of the skin is 

under these cireiiin.stances dirticiiU or im|tossil)le, mid the woiiiitl on this 
acTOunt is very liable to becoiiu infected. The thick layer of adipose 
tissue mav impede the .satisfactory c.\|)osiire of deep parts, and also 
interferes with the e.xaet do.sure of the wound; its blood-supply is poor 
and hence slou)ihin<; and cellulitis are likely to occur, especially if the 
nuirgins of the skin incision have been nmch undermined. These 
facts hel]> to explain the bad jirofjuosis in cases of stranptlated umbilical 
hernia, which nearly always occurs in excessively obese patients. The 
mortalitv ifter r)perations in these cases is very hijxh.and is a jjreat 
ccmtrast io the results after operations for strangulated femoral and 
inguinal hernias, which are not usually associated with obesity. 

The pro<;nosis in malijinant disease. (-.</. of the breast, is worse in 
obese than in spare patients. The <;rowth extends widely in the fat, and 
its limits eaniurt be recofjnised ; the presence of the fat, to»», obscures 
und lenders difficult the reco-initicm and complete removal of outlying 
nodules and of "'Mliu jr,.(l crlands. 

Haemophilia i.s a contra-indication to any but an absolutely essential 
and neces.sary operation. It is a rare condition, and as nothinfi 
abnormal i.s usually noticed until the ha'inorrha;;e occurs, the surjteon 
often does not suspect it until after the operation. Most serious ami 
even fatal hsemorrhage may occur after the most trivial procedures, such 
as extraction of a tooth or incisinji an abscess. It must be remembered 
that tliou^di the tendency to excessive bleeding is usually noticed at a 
very earlv a^e. the child may reach the nitc of eij;ht years or more before 
any abnormal liability to bleed is noticed. Should the patient live .so Ion;;, 
the tendency to bleed diminishes towards middle a^'e. 

Itotiu lymphaticu is a condition about which litt'.e is known, 
but which is of the greatest importance both to the surgeon and the 
anirsthetist. It is characterised by erdargement of the thymus, and a 
general increase of the lymphatic tis,sues of the body, which may be 
indicated bv .slight enlar<;ement of the lymphatic glands, eidargenieiit of 
the tonsils, the presence of adenoids and a palpable spleen. 
patients are generally pale flabby children, frequently rickety, who in 
spite of an unhealthy appearance are usually thought to be (piite well. 
The subjects of this disease are liable to die suddenly from some apparently 
very trivial ; death may take place either during or shortly after 
the administration of au ana'sthetic, or from shock after an opera- 
tion, often for .some comparatively slight trouble such as adenoids. 
Postmortem nothing to account for the suildeii death is usually found, 
except the excess of lymphoid tissue. The exact way in which death 
is caused is thus still a matter of doubt. The symptoms are so vague 
that status lymphaticus can scarcely be diagnosed though it may 
sometimes be" suspected. Needless to say, under these circumstances 
the administration of au anirsthetic or any surgical operation must be 
undertaken with great caution. 

Other general constitutional conditions such . tuberculosis, syphilis, 
rheumatism, and gout are not in them.selves of great importance in 
relation to operative treatment. Their chief importance is that they may 
be the cause of serious visceral troubles, which will be discussed in detail 
later on. Of course no operation should be performed during an acute 


attack ..f pout ..r rheumatwm.or duriiiK the pritnary or sec.maarv stajr.-s 
of svphilis, unless it were most urp-ntly calle.l for. Apart from this, an ! 
in tl .. a».s,.n<M. ..f visreral .•..n.pli.ations, there is »« 
pltie»t« should not do well Tut-en ulous patients who r«,«,re smipcal 
treatment stand even extensive ..perations well. AcUve 
phthisU is, however, a strong contra-indicat.on t.. the op.|.atu^ 

co-existing surgical tuberculous disease, unless for the relief of some 

"'"7t^:-TwTocessarv to consider the inlluenee which lesions of the 
vari.nis viseera exercise upon the prognosis and the results of surgical 
..perations. Verv con.n.onlv when an operation is reeommended the 
Ttien or his will ask " What is the risk >. " or " Is the operation 
Sangerous ( " These are f,v.,uently .lillicult .p.estions to answer. No 
operation is entirely free fron. risk, even in a v„un^' an.l n.l.ust ,nd.v..lua 
«^h, as far as one can tell, prfectly health); organs. when a 

death does occur during an».8thesia, it is surprising how of ten the operation 
is of a co.npaiativelv trivial nature, such as removal of adenoids or 
circumcision in an aj.parentlv healthy patient. Death «tben often due 
tosonie unsuspecte.1 o.' undia^'n..sal.le tr..ul.le su. h as the status lymphati- 
cl The danger is naturallv when the patient has some 
definite organic disease. f..r thou;:!, he nmy survive the a. tual ana-sthe ic 
and operation, yet death may still oc ur after a longer or shorter nteru 
fron, the additional strain thrown upon the diseased organ, or the Mtal 
Lowers n,av be so depressed that the patient dies from post-operative 
shock It is thus of the greatest importance that some examination of 
the chief or-MMs should l.e carried out before all except the most urgent 
ooerations. " Inthelatterthisexan.ination niav be reduced to a minimum, 
or even omitted altogether. f<.r the disease or injuiy. a .lep.essed fracture 
of the skull or a strangulated hernia for i.islan, e may be such that unless 
quicklv relieved death will surely and .puckly occur. I nder thes, 
circunista.ices anv examination which will delay the operation must be 
avoided; anv risk, however serious, has to be taken. 

1„ voun.' an.l healtl.v patients an elaborate investigation pf all organs 
is n.,t usually called for. The patient s,al appearance is noted and 
he is ..uestioned with reference tu previous illn.'sses and his general healthy 
It should, however, be an invariable rule before any operation, even of 
the most trifling description, if a general ana-sthet,c is re.pnred. that 
the condition of the beart and circulation should be ascertained by actual 
exan,inati..n. and tl t the urine should be carefully tested, especially 
for the presen. e of su^ar and albumen. Neglect of these precautions may 
result in a lamentable di.saster. . 

The influence of >.i.cerai lesions upon the provmosis of ope ati%. 
treatment may be considered under the following two heads, (a) As 
reaards the immediate danger of the o,„raliun Here ,t is necessary to 
estimate the effect of the anesthetic and the shock of the operatioi, upon 
the diseased organ. We have already seen that even when serious v,sceral 
disease is known to exist. operati<.n may be strongly indicated as theonl> 
possible means of saving the patient s life 1 he dangers of the anaesthetic 
may then be usually with the help of a skilled ana'sthetist by 
the use of modern apparatus and methods, or by the emplovmcut of 
local or of spinal ana-sthesia. These patients, however, may be unable 
to rallv after the operation *he diseased organ may fail, or some compli- 
cation mav develop which % lead to a fatal termination. 



{h) Theeffvi t iijdivU'niitn Ufmn the uUitmIe result oj the »})eratifm. Even 
\\hfre IK) iiiiiiuMliato tlaiiKcr i.s aiiticiiiiitwl from the ann'sthctic or tho opiT- 
tttion. the prohuhle ctTft t of the viHcoral trouble upon the ultiniatc rt-sult 
must bo carffully considcn il. For instancf. if an fltli'rly patii'iit is known 
to suffer from chronic Bri^lit's diseuM*. or from a serious valvular lesion 
of the heart, one would not recommend an operation for the rudicul cure 
of an uncomplicated hernia, for. apart from the immediate rUks. the 
visceral <Usease is likely to prove fatal in the course of a few months or 
vears. On the other hand, should such a patient have a stran^'ulated 
hernia, one wouhl unhesitatingly advise him to take the risk of the 
operation. In this while the immediate daniier would not be 
excessive, the alternative to operation wouhl be certain death from •)!>- 
struction. The existence of vis< eral trouble will in many serious diseases 
lead the surpeon to advise palliative treatment in preference to a radical 
operation. Thi si' points have especially to be considered before advising 
extensive operations for the removal of maliirnant firowths in elderly 
patients. The present writer some time a^o removed an extensive j;rowth 
from the floor of the mouth of a patient w ho had a trace of albui.ien in his 
urine. Thou<;h at the time of the operation this man aj)peared to be 
strong and in good health, yet he died only four month.s later of cardiac 
dilatation and failure secomlary to the chronic renal disease. 

Heart and Cironlatory System. Preliminary examination of the heart 
and the circulatory system should be systematically carrieti out, chiefly 
on recount of the danger of the aiursthetic and i)ost-operative 8hf)ck to a 
patient suffering from valvidar di.sease or myo( anlial (le<.'eiieration.' 

In addition to an examination of the cardiac souiuls. it is of the 
greatest importance to ascertain whether there is any hypertrophy or 
dilatation of the heart, and in the event of this to look ftir any signs of 
circulatory failure such as oedema, enlargement of the liver, or an unduly 
rapid or irregular pulse, .\dvanced valvtdar disease is an absolute 
contra-indication to any but the most indispensable operations. Fibroid 
or fatty degeneration of the myocardium is ])robably of at least as great 
importance as valvular disease and is far more difficult to detect. Before 
deciding upon an operation upon patients with these serious lesions, the 
risk of the operation and the ultimate benefit to be expected be 
carefully considered. Such patients require careful anajsthetisation. but 
then usually take the anicsthetic well ; iiuleed, the pulse of a patient 
with valvular disease freipiently becomes sh)wer and more regular when 
he is under the influence of an ana'sthetic. During the administration 
the greatest care nmst be taken to avoid any obstruction to res; "-ition. 
for a diseased heart is liable to fail with the extra .stress thrown upon 
it by even a slight degree of asphyxia. The successful termination of the 
anaesthetic and the operation by no means ends the danger for such a 
patient, for after he has been returned to bed the pulse may gradually 
get w eaker, and death may still occur after a longer or shorter ititerval from 
cardiac failure. The existence of cardiac disease has. as a rule, no adverse 
influence upon the wound, which may be expected to heal in a normal 
manner. In advanced cases of valvular disease, however, odenia may 
appear around the wound, and there then is an increased liability to 
infection. Quite apart from any gross lesion of the heart, the circulation 

I Dr. Jdscph ('. UI(H)iln(M.(l [Aiiiiiil' i<j Siinjinj. l'.»12. vol Iv. |i. (i4I) in a \«s,\* T im 
" The E»timtttiiiii of the Vital Resistain i- of thi- I'atirnt with Ueferfnce to the Pos.sibihly of 
Recovery after Opemtioiu," insist! also on the importance of measuring the biooi) pressure. 

BMV be •erioudy depressed ns tlip result ..f «<.m.' cl.n.i.ic .li.s.-as.. s.u li an 
tulinrttlnms of a boie or joint with ..lui.y mnuH.-H. ..r fion. .souic s.nom 
Mute tr..ublo aueh as intestinal obetruction or pentonitw. In the 
latter. uuM. if for anv reason delay has occurred, th.' imW> inuv be 
HO rui.i.l a„a .snu,ll that it . an s. ar.vly bo felt <.r count«l ; if in a.hli ion 
the extren.itie.. an- col.i. .l.-ath .nav shortly be ex|,...-tea. and anv o,H.ration 
is contra-indicated. When the . ireuhifmn is h s. severely at e. ted. h. 
operation may Ih' carried out u..der s,,..,.! or h,.al anasthesia f a 
ir'noral ana-stletic is considered un.les.ral.le. Ni. h patM-nts ..ften take 
a ceneral uiursthetir surprisingly well, but only too frequently «f er 
the operation the ,.ul«e apain fails, the heart does not res|M,n.l to stimula- 
tion or infusion. an.l the patient dies. In adcUtion to the »f 
the heart, attention should also be .lirecte.1 to the character of the 
arteries. K.xten.sive atheroma means that the tissues are degenerate 
and that their nutriti..n is imperfe<tly carrie.l out. .V thickened arterial 
wall or a high tension pulse may direct the attentwrn of the »urRe«m to 
arterio-sclerosis or to chronic renal disease. , . . , ^ , 

If there is anv diseaws of the heart or of the circulatory system, and 
the ..... ration, thou-h desirable, is not urgently necessary, the operation 
may ..ften with advantage be postponed for some days or weeks, during 
whieh time the .■aidiaclesi<.n is treated. , , u 

While the operation is in progress th.- sui>.'e..n sht.ul.l always observe 
the amount of bleeding and the colour ..f th.' l.loo.l. In this way nnix.rtant 
indications of depression of the circulation will ..ften I..; I.r..uj;ht t.. Ins 
notice. In severe cases of cardiac failure an e.Ntensive iiu^i.sK.n mav be 
made with nru. ti. ullv no hemorrhage, and the few drops of blood which 
escape will l..> .listinttly bluish in colour. These are indications for 
immediate attention t.) the c.ndition ..f the patient. 

Respiratory System. A patient with any recent acute lung ..r 
pleural dis.-ase is naturally a bad subje. t f..r an ana sth.'tu' ..r an ..p.-ration. 
Occasionally, however, operation may be th.' only po.ssibl.' m.-th..dof 
treatment of some complication, an empyema for instance. I nder such 
circumstances the operation, or rather the ana«8thetic, niay be accompanied 
bv eonsi.lerable risk. Speaking of these cases. Sir Frederick Hewitt' 
savs • The most eases are th.ise in which respiratory em- 
ba'rrassment from n . ent pleurisy ..r pleur..-pneum..nia "'-e.xists with 
quick and hampere.l ear.lia.' action. Wh.'i. th." patient is .sh-htly .l.isky 
hU temperature elevated, his breathing rapid and his pulse accelerated 
and sharp under the finger, the use of an aiuvsthetic is attend.-.! by 
consi.leral.l.' risk. This risk is greater in patients with previously fatty 
and dilate.l hearts than in others." Means for mininusing this risk 
will be consi.ler.'.l when the ..peration for empyema is described, but m 
verv serious cases a local aiuesth.'tic may be employed. Patients with 
Bligk chronic bn.nchitis. phthisis or emphy.sema may be e.Np.-eti-.l to 
take an amesthetic and to stand an operation well, provided that the 
heart is not secondarily affected. Obese patients witli l.n.nehiti.s ar." 
very bad subjects. They may be unable to breathe m the recumbent 
position ; the pulmonary trouble may be increased by the a.uesthetic and 
k-ad to failure ..f the heart, which is probably already weakened by fatty 
infiltration and degeneration. A bronchitic patient presents other 
difficulties to the surgeon. The continual coughmg will make the patient 
restless and, especially after abdominal operations, will throw great strain 
i AntnUutiei. 1901. p. 127. 


upon thf ttitvheit. BandngM aroond the che8t or the u»Ml..m. ii if ti^lit 
|€.' much dvspwra and diMomfort. while if Unmc t\w\ are vory 
lial)li- to Hlip ttiwl the dreiwinpi to borome diaiilaml. An anmithrtic. 

^'^.IM•<•illlI^• .-th.-r. inav soiiu'tlnu's a|.|.ar.Mitly be the caiwe of ar actttc 
uttuik of broii.liitis or ixi.-ninoiiia. 'I'll.' lutter may »h> a bmnrh«»- 
pneumonia wh.-n it is prol.aMv .lu.- to iini..Tl.'. t ..xiH-. toration of . atarrlml 
«ecrt>tion. or a lobar piifumonia wli.-ii tlir mlialation may he tlicpri'- 
di>p«mng caiwe. In ran- nisos an aii.i Htliftic may r. i ai tivt- a latent 
tub«'n-ulou8 diMiaae. In elderly pati> uts proLinjii-il n-st in Ii.mI may Irad 
to <on>ji-stion of the bnwHi of the lunjis. a con«htion wlm li is lik. ly t.. 
(i..v(>loi> into hvpc atic i)ii.'umoiiia. This in a very fatal iMwt-oiH-rutive 
loniplication in sn. li juti.-nts ami is best avoided by p-ttinn them up a» 
8otm a8 possible. . 

The condition of the umx r rt xftiralorn inissiuii s slioul.l always I..- noteil. 
for any obstruction to the free flow of air is j.ntty <» rtani. owm^; to 
venotwenitorgement. t*>be increased tluiinganH'stli. sia. W lien the lifl'l of 
operation is the buccal or pliarvnjieal cavity, the r.-moval of a mali^'iiaiil 
.Towth of th.' toii;:iio. Iloor of the mouth, or the pharvn.\. for example, 
blood niav be drawn into tlie larynx and seriously obstruct breathiiiK. 
Kven when it eauses no ai tnal ol.stnictioii. portions of dot may be inhaled 
and tlms be the 8tartin>!-pi>int of a septie l)n mcho-pneumoiiia a .serious 
danger after these operations. In .such cas. s iiit rat rai h. al msutliation 
of ether '*f» the moat satisfactory method of maintaining uiuestln-iia. ami 
is m««t efficient in preventing the entrance <.f blood into the respiratory 
passages. Plugging the pharvnx with steri1i.sed gauze after a prehnunarv 
laryngotomv. or ('rile s method of inducing aniesthesia by means of nasal 
tu^ with sut)se.|iieiit packin - • the pharynx may also be em])loyed. 

Tunimiis of the neck. ( lally an enlarged thyroid, may be a 
considerable source of danger .luring ana-sthesia. This to a great extent 
is mechanical, and is the result of asphyxia brought about by the pressure 
of the tumour, which is increased in siae by vas( ular engorgement, upon 
the trachea. These dangers atid the means by which they may be over- 
come will be fully considered when the operative treatment of goitre 
is di.scu8.sed. , 

Urinary System. An examination «f the urine should be nuule as 
a routine measure before every surgical operation. Should albumen 
• iresent everv endeavour should be made to ascertain its origin and it.s 
lificance. If necessary the centrifugalised deposit should be examined 
ii.icroscopicallv for the presence of casts, for if the albumen is the result 
of anv form .if nephritis it have a most important bearing upon 
the progiwsis an.l the treatment. Pati.'iits sutTering friuu Bright 8 
disease are certain'^ Sail subjects for operati.)n. Th.-y may be unable 
to rally from the si...i k of a severe .)p.'ration. .>wiMg probably to the 
imperfect excretion of t.)xic products. In other cases definite symptoms 
of uremia mav supervene or even suppressi.)n of urine, either of which 
is practirallv c.-rtain to terminate fatally. These serious complications 
are esjieciallv likelv to occur when the operation is for 8<»me injury or 
disease of the pelvic .)r iriial organs. It must also be remembered that 
patients with chr.)nic nephritis are very liabl.- t.) a number of serious 
complications. Of these cardiac dilation and hyp.Ttrophv which may 
terminate in heart failure is the most in!i)ortant. Other complications, 
such as bronchitis, pleurisy, pneumonia, pericarditis, and peritomtis, 

I .s>« p. "81. 


arc of u <■ hroiiic iiiflumnuitofy MtttW. Any of tbew may readily appear 
as f I..- n siilt of the . xtra strain nf an oprntkm upon the »y^^ »i 
aln pivH.M.t th.-v will 1... made worw. and >n either caae 
the patient i.s v.-rv lik.'lv to nw v»mh. Lastly, an the reauH of changM 
in the va«ular Hvst.'iii uii.l the detici.-i.t excretion of toxic i)r(Mlucta, 
various cutanwrns lesions, such us wzeina, Im)iIs. curhuncles. ami even 
erVMpelas. mav be present or are likely to develop. 1 hese. in 
addition to a areatlv increuse.1 liability to woui»l inf.'< tion. may senoiu^ 
and acivenk-lv afT.H t the pnijm^i «)f the patient. The mere presence of 
albumen is. of t ...irs. . in its. lf not a contra imhcation to operation ; m 
w.imeii it mav Im' the result of a vajrinal ilis.-harjje. while m men It may be 
.l.-i lv.-a fr.)m's..m..|.'sion in the ....'thra or the'r. An explanation of 
the ttlbuniiimria should, however, in all cases be .s..iinl.t for. Kveii when 
chronic nephritis iakiMiwn to exist, operations are not i>.."c.>.s.saniy t""Ya- 
iiidicated ; »ttch patienta may do well even after severe op. rat.ons. \> hat 
is needed is a careful consideration and e«timati«>n ..f the risks t.. be 
run an.l th.- b.-n.-lits to be exprted. The latter wi I often be fouiid to 
altoL'etlier <-t\s.M):l. the former. If ixwsible in such a case » P«wa?' 
r.'st an.l tr. atment of the nephritis and its complicationa should precede 
the Buruieal treatment. i i • i 

Should the oix-ration be re.iuire.l for .some disease of the ki.lne\s 
or other portion of the genito-urinary tract, it is most n^essarv to 
ascertain the source of anv albuminuria, luematuna, or pyuria, ami to 
inv.-sti-at.- th.' .•x<r.'t..rv functions ot the kidneys, tortunately the 
m.Hh rn m.' ..f cystoscopy, and cathetensation of the 
ureters, with .-xaminati.... of th.- uriiu' .s.-cret.-d by each kidnev ire of the s.Mvi.e in enabling! one to estimate the functional condition 
of thfsi- .>ri:ans. » i 

We may here consider the question of .)perations upon patients who 
are sufTerinff from diabetes. Such patients are very ba.l subjects for 
operative treatment, and this disease shoul.l contra-mdicate any except 
absolut.-ly necessary operations. The dangers mny be considered in tfte 
throe f.illowinfj f,'r.mps. ..-tj- 

((/) Thrn- is a dUliiirt ddtujer Hint the imtient die of diabetic coma. 
This con.liti..!. usuallv develops as the r.-sult of mental <.r ph>7*ical shock 
in the subjects of this disease. An aiuisth.'tic or an operation is thus 
verv likelv to be the e.xcitinR cause. Th.' liability to coma is much 
diininish.'.l if the is being treated and the amount of su^ar lost is 
iin.l.'r c..ntrol. Ksp.'ciallv dangerous are those cases m which the disease 
is unreco.'iiised and untreat.-d. when death may unexpectedly f oUow a 
c.)mi)arativelv trivial operati..... For instance, the writer knows of the 
case of a v.)un}j man a>;.'d -.'D wh.) was op-rated upon for a varicocele. 
Next day the patient became comatose, and the urine, then tested for the 
first time, was found to contain largo .piantities of supar 

(b) The tissues of a diabetic patietU are uttdulu liable to infection bij 
piionenic orqnnimiH. The wound is thus liable to slough suppurate, or to 
become the starting-point ..f a sprea.ling cellulitis which is very difiicult 
to treat Can-'reno. usuallv m.)ist in character, may occur in diabetics, 
either spontaneous! v or affr ..p...ati.)n. In either case arterial degen- 
erati.m and peripheral neuritis, which commonly co-exist are probably 
predisposing causes. The gangrene usually ocr-urs in elderly patients, 
is coiinnonly moist in character, spreads rap^ :'y, and almost always 
ends fatallv. 


(, ) C riain i-nmi>l,<<,l„ms ,irr Idihi to •xriir in dinhriie /w/«>»rf» whkk 
will uHMuriMllv Imvf a s.-rif.iis lM-arii>jr uim.ii tli.' |iri)>!ii.wis. In iiiUlitHMl 
to the M'ptir tri>ulilcs mciitiniuMl uImiv.-. X\w .>*kiii nmv • wat oI 

VsrioUH IfsioiiM Hiit li us iTZfiiia. ImhIs. ..r fvcii . iiihtiiu l.-s « it nuist 

be remembered tlwt a Okbt'tir U v.Ty liablo t. iul«'r. ul..uM 

(liwttw of the lunitii. It is alwavs tb-Hinible in ih;i»n .wu.'iitH to uoet- 
iM.ii.- if i«.Hsil.l.-. aiiv (.jMTiitioii until treatment by U, -ng anU by drum 
luLs i)r.Miu<v.l u c.nmid.Tubl.' tl."( r.-iii«> in the excretion of aanar. The 
<luiii{.T» of tlir operation will in this wmv Im^ j;ivatlv .linmush.-tl. Should 
the fon.lition b«' r.'«ur.l.'<l as >ilvi..surui latli. r than as ■liab.'t,.H, that 
is when there w but a small amount ..f siiuar an.l iH.lyuiia. th." a. tual 
operation risk in wM acrious. It nnwt. howivir, be rfn»fnilR'ri'.l that a 
pewiHt. nt f-lyc «wMria in a >{rave rendition and that auch caww n»ay eventu- 
allv (U'vcloi) into tnif lUttbetes. 

Alimentary System. Diwuiw'!* of the «liffPHtive tract will naturally 
havi' a iDnsidiTahlf flT.-ct upon tin' tim. ial health an.l condition of the 
patient. Tli.' subjects of »hroi;ir .lvsp..psia. an.l th .m- HuffennK front 
chronic coi - ipation, are not lik.'iv to 1m- in a satisfactoi v stat.' for a 
severe operation, and it must \w ronienilH-rctl that tins.- troubles an- 
certain to be increaml bv the aubsetjuent reat in bed. Op. rat ions sh. .ul.l 
I)., avoi.l.'d. if poMible. in patient* with serioua orgamc iliscuse of tlu- 
iiv. r suc h s cirrhosis, lunlaceous or fatty disease. Colitis, dysenterj-. 
au.lotluT chronic int.-stinal.lis..r.l.'rsar.- alsocontra-imlicatioiistogeneral 
(.iR-rations. tlioujih in tins.' an.l otti.'r similar conditions surgical treat- 
ment inav be rcjuired. an.l succ.-ssfullv carri.'.l out. t..r th.- int.'stinal 
disease itself. The con.liti.)i> of the mouth uiul teeth shonl.l alwavsh.- 
observed, and if septic or carious teeth are present they sIkmiM. iltim.- 
iHM inits. he attcndetl to before the operation. This is cspe< iallv tlcsiruble 
if t he operation is for some disease in the mouth or pharynx. Apart from 
its effect ujion .lif.'. sti..n an.l the ^eiK'nil health, oral sepsis means that 
the iwtient has a s.'ptic f.K Us from \vhi< h or};aiiisni'"iinv be cametl by the 
blood-stream to the wouii.l. or inilc.-.l t.> any pir ■ ' i •■ • "Iv. ^ 

larvooi Syitam. The influence of fun. ti. .1 r.,ea,,.- ' ' 
svstem haa been indicated while the que8ti..n ' iuoer..n,. la >.as un.l. r 
.liscussi.).-.. An hysterical patient ia very Mi.- to iierv!.u.s .ttacks 
either before or after the operation ; inthel 'r. r ^ » (lu-s-- ar. likely 
seriouslv to int.-rf.-r.- with th.- aft.'r-treatm— 1. .^"•■*^^Stt:. orerative 

measures mav he carri.'.l out in th.> insan.' with .< I prosr.''. | -f nuccess. 

provided tha"t there is no mark.'.l ho.lilv diseas. . l thai " are no 
unclean or mischievous hal)it.s which woul.l serious' , n ' i > isfactory 
result. When, however, the patient is viol.'iit .>r luni.. .il an op.-ration 
haa but a faint prospect of success. When there is a definite or>?anic 
nervous trouble, such as locomotor ataxy for instance. n«me but essential 
operations shonl.l I).' carri.'.l out. These diseases may. however, run a 
very chronic course, and the patients often do well in spite of the disease 
of the nervous svstem. When <;rav.' ar.' caus.'.l by some 
lesion of the nervous system which is amenable to suijiical tr.'atm.'iit. an 
operation may be successful even wh.-n the con.lition of th.' patient 
appears t» be most desperate. He may be absolutely comatos.- as the 
result of increased intra-cranial pressure after a dcpres.-ed fracture. 
lui'n\orrha;;e from tlx' middle meningeal artery, or fmm a cerebral abscess, 
and vet recover after these conditions have been relieved. 



Oeneral Preparation. It is now iiecessarv to consider in some 
detail the preliininarv treatment and the general preparation. It is 
advisable in all cases that the patient should be under observation in the 
hospital ward, nursini; home, or wherever the treatment is to be carried 
out. for at twenty-four hours beforehand. ( )f course in irrave .surgical 
eiiii'rjreiitics. time is of sucli importance that the o|)eration nnist be 
])eif()inu'(l as soon as possible, at the e.Npeiise of or even to the total 
exchisioii of all these precautions. In many cases a lonj;er jieriod than 
twenty-four hours is desirable, and. us has already been indicated, when 
there is any adverse local or constitutional trouble ample time should if 
possible be allowetl for its satisfactory treatment. 

Immediately upon admi.ssion to the in.stituti(m the patient .should have 
a hot l)atli and tli<ii' 'ii.'lily wa.;li the whole body. Should the local 
or constitutional coiulition riMuler this undesirable, he is at once put to 
bed and then thoroui.'hly washed by a mir,se. This will be repeated daily 
throufih the whole perioil of preliminary observation. During this time 
the condition of the teeth and nuiuth should also always receive attention, 
espei iaily if the operation is for some disease of the upper respiratory 
passaj;es. When tartar is present, or when there are septic or carious 
teeth or roots, it is desiiable that these should receive attention before the 
operation. When troubles are not present, the use of the tooth- 
brush, and the occasional use of some anti.septic ?nouth-wash such as 
chino.sol I in KMHt. are all that are re((uired. Any other focus of infection 
such as tonsillitis, nasal catarrh, boils or other cutaneous lesions, especially 
if in or near the field of operation. shouM also receive careful attention. 
The bowels should be emptied by a ])ur;.'ative administered on the 
precedinji day. follow(>d by a saline ajierient or soap and water I'liema 
six hours before the operation. Should the operation be for some of the rectum oi other part of the intestinal tract, it is most 
desirable that the bowel shall be empty. In the former case, an opera- 
tion for piles for example, a coj)ious enema should be administered about 
eight hours before the operation. On the other liand the purging 
must not be overdone, for it is naturally a bad thiiif; for the ojieration to 
take place wlnl(> the patient has an attack of diarrlm a from this cause. 
Excessive ]iiii!.'ation. too. is likely to have a serious etl'ect in elderlv 
patients, or in those suifering from an exhausting' disease. 

It is desirable that for some days beforehand only light and easily 
digestible food shouhl be t«ken. The stomach should always be empty 
during the administration of an aiuestlietic. and hence the time of the meal 
immediately preceding will dejM'nd upon the hour at which the operation 
will take |)hice : it is <.'ciierally a^'reed that the best time is the morning 
at an early hour. In tiiiscase a healthy ailult will have had nothing after 
his evening meal the preceding day. with perhaps the exception of a cup 
of weak tea two or three hours before. 

If. however, the patient s general condition is weak, or in old people, 
such long starvation is undesirable. These mav be allowed small oe- 
casi»)nal feeds of clear soup or chicken broth throughout the night. In 
some cases where there is much exhaustion a little alcohol in the form 
of weak brandy or whisky and water may also be allowed. If the oi)era- 
tiun ia to take place at any other hour of the day the last meal should, as 


a general rule, be given about five hours before the commencement of the 

Th« bladdor should always he oniptiod bpforc the patient is liroufiht 
into the operating room. Slioulil there be any ((uestioii as t<> this liaviiii; 
been satisfactorily aeeoinplished. a catheter -liouid be passed, especially 
before abdominal or jx'lvic operations. The patient should be suitably 
clothed in a clean nijiht-jjosvn or pyjama suit ; the former is usually to bo 
preferred, and should be made to completely uid>uttou at the back so that 
it may be readily adjusted or removed as recjuired during the operation. 
In weak and exhausted patients, and especially in elderly people and 
childrtMi. additiciUal warmth may be .secured by loosely baiidauiiij; the 
limbs and any part of the body which need not be exposed, over a thin 
coveriiii; of cotton-wool or jiampee tissue. Any false teeth must be 
removed before the coninu'iicement of the ainesthetic. 

Aupsil. It is now necessary to consider a nu)st important series 
of preparations and precautions, the object of which is to prevent infection 
of the wound. In other words we have to describe the means for securin<» 
.Vsepsis. A short sketch is :ill that can here be jjiveii ; for fuller details 
the reader is referred to .some such book as Lock wood's Asijitic Sidijiri/ 
(litO'.t). from which manv of tin- facts described below are taken. 

The importance of asepsis is now universally adiiiitteil. If any 
wound suppurates, even to the slightest extent, it means that infection 
has somehow occurred ; in the ".neat majority of cases this is brought 
about by some failure in the aseptic precautions of the siu';;eoii or his 
a.ssistaiits. The universal presence of pathoi^enic orfianisms which are the 
cause of inHanunation. suppuration, and serious complications such as 
pya-mia and septica>mia. has been amply proved. Any object, be it 
II li<.'iiture. an instrument, the hand of the suru'eon or the skin of the 
patient, nuist be rei.'arded as septic and liable to infect a wound, unless 
it has been specially prepared to ensure the destruction of all organisms 
which may be present. Infection of a wound may be brought about in 
any of the foUowini; wa vs. 

(1) Air Inject ion. Thou).'h the air may contain large numbers of 
micro-organisms.' both pathogenic and non-pathogenic, this source of 
infection is not of great importance provided that certain precautions are 
taken. When the an is dry and contains much dust, many organisms 
will be present ; if the air is perfectly still the dust and bacteria gravitate, 
with the result that the air (loes not infect culture-plates. Also when the 
air is 8aturate(l with moisture it is practicallv sterile. 

Organisms are with ditficidty detai'he(l from a moist surface ; dust 
must therefore be both carefully and tli<uoughly removed from the ope- 
rating room. E.xpired air. in ordinary (juiet l)reatliing. is stated to be 
practically free from organisms. When, however, as happens in coughing, 
sneezing, or talking, small particles of saliva or nasal mucus are projected, 
various pathogenic organisms are certain to be present. Streptococci, 
for instance, are always fouiul in .saliva. Particles of dust from the hair 
are naturally septic and can readily infect a wouiul. It is thus very 
necessary that the surgeon and his assistants should take precautions to 

' Mr. L'"'kwo<"l quotes exiHTiiucnt?" in which st<?rili«wl rulture-jtlatt's wen- cxfrnscd 
for a frw iniiiiitr.s in lidspital wards and <i|M'ratin(! theatrt>«. AninnK the nrKanisniM 
foiinil were the Uacillns iiih. Stii|ihylci( i>( ( iis i)yi>(ii'ni'S aureus an<l allm^^. as wrll ax many 
non-pathof;i'nii' inoiilds and .«ari iii.i . Stri'iitiu oii ii» pyuKenex was fimnd in the air of 
the erynipeiaa ward, whilu the tubi'icle bacillus was very cumiuuuly present in the air 
of waidi occupied by phtUsioal patienU. 


prevent tliis accident, wliicli is exci'ediiiirly likely to happen on bending; 
over a wound, especiallv if two heads should come into contact. It may 
here be inentione(l that Hies and other in.sects may be the means of con- 
veyinj; .septic organisms .1 iid so infectinj; a wound. 

('2) Skin InfectiiDi. Infection of the wound by orj^anisms which are 
found cither upon the surface or in the deeper layers of the skin is 
undoubtedly a \ cry connnon cause of suppuration aft^r operations. The 
wound may be infected from the skin of the patient «.r from the hands of 
tile surgeon or of any of his tants. 

The surface of the human skin swarms with various cocci, bacteria, 
and other orjianisnis both pathoi.'enic and non-pathof;enic. e\en in a 
cleanly individual ; tiiis is e,spe< ially the case when there is any hair 
present to collect and retain particles of dust. VVhen the skin is obviously 
dirty, or wheii any disease such as eczema is ])resent, their variety and 
nund)er are fjreatly increased. Orjianisms are certain, too. to be present 
in larjje numbers in any natuial folds, wrinkles, or de|)ressions. such as 
the a.xilhe. the j;roin. or tiie umbilicus. Such localities always rei|uire 
careful attention, anil even then, owiiij.' to the numerous sweat and 
sebaceous f.'lands and a liability to dermatiti- are very diflBcult to render 
surgically clean. With regard to the hands of the surgeon, the grooves 
beneath the nails, and any loose tags of skin, are certain to contain and 
shelter many infcctixc organisms. Needless to say, rough, cracked, or 
chapped hands, or the presence of any .septic lesion, moan many organisms 
which it will be dillicult oi' impo.ssible to de.-<troy even by the most careful 
cleaiisini; proci'.ss. It is neces.sary to bear in mind that imnierous cocci 
and bacteria always exist in the (Keeper layers of the skin. This is 
largely owing to the presence of the sebaceous and the sweat glands. 
If the surface of the skin is carefully cleaiised. and perspiration stibse- 
quently occurs, these septic orj.'anisnis are brought to the surface in large 
mmibers by the secretion ; their pres(>nce may also be proved if. after the 
skin has been jtrejiared. material is si|ueeze(l from the sebaceous glands. 

'1 he fatty nature of the secretion also to a grea'. extent protects the 
organisms and thus hinders their destruction by watery antiseptic solutions 
which do not dissolve fatty substances. 

(3) Infection by Imtrumcnts. I'nless careful precautions are taken, 
a clean wound may be easily infected by the use of instruments which 
have previously been employed for a septic case. Blood. j)us. or other 
se]>tic material niav readily lodge in the serrations or joints of such 
instruments as forceps or .sci.ssors. Instruments are now mad<' us far 
a,s possible entirely of metal, with only necessary grooves and ridges, in 
order to facilitate cleaning. After use. all blood or discharge nnist be 
removed by careful washing and brushing ; many such instruments as 
forceps and scissors are constructed with detachable joints which allow the 
two halves of the instrument to be separated during the cleansing process. 
If not properly cleaned, even boiling may fail ' > .a'ct perfect .sterilisation, 
for the albumen of the blood will be coagulated antl will thus form an 
envelope which is likely to protect organisms and especially spores from 
the action of antiseptic lotions, or even for some time from the action of 
boiltng water. 

(4) Jnfpriinn hif Tiweh. Stmhs. nnii llressings. I'nless all these articles 
are freshly and efTectively sterilised before the operation they may 
easily infect the wound. Towels, for instance, though fresh from the 
laundry and apparently t|uite clean, are in reality extremely septic, 


partly owing to rontaniinntion hy dust. l)iit niso tiy tin- water in which 
thov wore washed, prohahly in roini)aiiy witli niiiny othrr .snilcil iiiitl 
(lirtv articlos. Dtv gauzes aii<l wools, even thoui;li inipn-iriiatcc! with 
antiseptics, will also collect dust and thus harbour nuiny organisms. 
Tnless recently sterilised, jjauzes should f>nly be applied to the wound 
after immersion in an antiseptic lotion. Marine sponges are now practi- 
cally obsolete, for, owing to their porous structure, when they have once 
been u.sed their sub8e({uont sterilisation is a matter of con !deral)le 
ditticulty and uncertainty. Their place is taken by .swabs of absorbent 
material such as <:ain<;ee tissue enclosed in liiyers of lmuzc. 

(")) Infection bif Sutiircx iind LiiinlKii n. All niateiMls used for ligatures 
and sutures are certain to be contaminated until they have been carefully 
sterilised. This is especially the case w ith catgut, which is j)repared from 
the intestines of sheep after the mucous membrane has beeii more or les.s 
thoroughly removed by scraping. Raw catgut, from its origin and mode 
of preparation, is thus certain to contain numerous pathogi'iiic organisms, 
and uidess elTectively sterilised is extremely likely to infect the wound. 
It is said that even anthra.K has been traiismitteij to a wound by im- 
perfectly sterilised catgut. 

This material has. however, many advantages in favour of its use for 
buried sutures : it is strong, pliable, easy to manipulate, aiul is eventually 
absorbed and is hence very g -nerally employed. Fortunately, though 
it cannoT i/C sterilised by boiling in water, there are other very effective 
methods of sterilisation which render it ijuite safe and reliable. 

(()) Infection hij Water. There is less danger of infection from water 
than might have been supposed, for tlumgh ordinary tap water may con- 
tain many bacteria, cocci and other organisms are chieHy saprophytes, 
and hence do not grow in living tissues. Septic organisms such as the 
Bacillus coli and various forms of .streptococci and .staphylcK'CK-ci may, how- 
ever be found, but in good tap water, such as is supplied in Londoti. these 
organisms, if present, occur oidy in very small mnnbeis. The wati'v may. 
however, be contaminated by dirty taps or by contact with im <• ^^»'vh• 
prepared vessels. In the operating tlu-atri's of (Juy's Hospital the water, 
both hot and cold, which is u.sed for preparing lotions and saline s'>lutions 
for irrigation and other purposes, is filtered through Berkefeld filters. 

This water is regularly examined bacteriologically. and organisms 
of any description are only found on rare occasions. ( "leansing or renewing 
the internal mechanism of the lilter then lesnlts in th ir disappearance. 
If taj) water is boiled for a few minutes, or if .intiseptics in the j)roportion 
re(|uired for making the ordinary lotions are added, all organisms are 
quickly destroyed. Boiled tap water may thus be tpiite .safely used for 
the preparation of lotions, or of .saline solutions for infusion or irrigation. 
Indeed, for the former purpose boileil tap water is preferable to distilled 
water, which usually contains i!iany organisms and may on this account 
be decidedly toxic. 

(7) Aiilo-inociildtion. Infection of the wouml by organisms cnnveyed 
by the patient s own b'lx-d-stream may certainly occur. It is. however, 
unlikely, and though its treijuencv cannot be ascertained, it is probably 
a very rare cause of suppuration compared with local infection of the 
wound. This is shown by the rarity of suppuration after an injury 
which does not wound the skin a simple fracture for instance. When 
it does occur there is nearly always some obvious local septic focus such 
as pyorrhoea alveolaris, a septic throat, or some septic ulcer or sinus. 


On this iicTKuiit it is liijihly ilesirahli' that any such trouble should be 
recognised and efficiently treated before the operation. 

It will now be necessary to consider tlie precautions which must be 
taken to guard against infection. tSterilisatioii may be effected either 
by the action of heat or by the use of chemical antiseptics. The f<»rnier 
is the more effective nietliod but cannot always be employed. The 
skin and other Hvinj; tissues, for instance, can only be cleansed by the 
mechanical processes of washinj; and irrijiatinn. and by tlie use of anti- 
septics. It nuLst be reniendjered that stroiijr aiiti.septic lotions may iiave 
a very serious etfect upon liNnng tis^ ^ the vitahty of whicli is prol)ably 
already lowered by injury or disease. The skin may be irritated, or even 
a "evere dermatitis may be produced ; delicate tissues may slouijh or ha v(> 
t' r vitality so (Icjjressed that their power of resistance to infecting 
oi^ianisms is i.'rt>atly diminished. 

\. Preparation of the Skin of the Patient. Two methods must be 
described. (1) lii/ aulixcjitic rouiprrssi .'i. This method is now but sehlom 
employed. After careful shaving for some distance around the proposed 
incision, the surgeon, having first carefully cleaned liis own hands, then 
thoroughly scrubs the skin with a sterilised naii-l)rusli and hot soap and 
water to which a little dilute licpior potassa; has been added. The 
process is then repeated with an antiseptic lotion such as lysol I per cent, 
or carl)()lic lotion I in H A comi)ress, consistinir of several layers of lint, 
which after sterilisation bv boilinu is soake<l in the same antiseptic 
solution, is then applied. This is covered with a layer of }.'utta-]i('r( ha 
tissue and is then bandaged in position. The compress remains in 
position for twelve or twenty-four lu)urs. or even loni;er before the opera- 
tion. In the latter case it is usually changed and a fresh compress 
similarly prepared applied every twelve hours. Unfortunately this 
treatment not infre(|ueMtly defeats its own object. The mechanical 
effect of the brush cond)ined with the irritant action of tlit> antiseptic may 
produce severe irritation of the skin or even an acute dermatitis. When 
this occurs, infecting organisms are certain to be i)resent and the operation 
must be postponed until the skin has recovered. It is now re((ij:nised 
that all irritation of the skin is harmful and that thorough washing 
with soap and hot water is the effectivi and irritating means 
of cleansinjj the skin. This will not (h-stroy the or^'anisms in the deejier 
layers, though the mechanical efYect of the wa.shinj: will, to a considerable 
extent, remove the secretion of the jjflands. Ahoholic solutions of 
antiseptics, such as biniodide of mercury 1 in UK Hi. have however a 
powerful action in destroying these cutaijeous organisms, pi becauae 
the alcohol dissolves fatty substances and thus secures gteb etration 
of tiie solution. 

(2) T/ir loditu- Miiliod. Within the ])ast few years it has also been 
recogni.sed that an alcoholic solution of iodine has remarkable po'vcrs of 
destroying the cutaneous organisms. The strength of the solution shoidd 
be between 2 per cent, and 5 per cent. The tincture of iodine (R.P.) 
contains 2J per cent, iodine and answers admirably. A solution of 
iodine in n'lethylated spirit should not be used, since the iodine readily 
evaporates from this and causes intense irritation of the eyes of those 
j)r(.'.;..!it in th<-- room. .\ Hiost important pojtst to remiMuber when iodine 
is used, is that for its efficient action the skin must be dry. This has 
led some surgeons to dispense with ])reliminary shaving of the skin. 
Hair is, however, of such importance in collecting dust that shaving is 


c(>rtaiiil%- desirable. It niuy be carried out bv means of a sharp drv 
razor without \M'ttin<; the skin, or if the razor is used after washiu}; and 
hifheritif;. the skin sliould. he thoroughly dried with a steriHsi d swal) and 
then treattil with alcohol or et.'ier before the application of the iwUne 
solution. The sterility of the skin may be tested bv examininp bacterio- 
loginally a thin snip through its entire thickness from the niarfiin of the 
operation incision. In one scries of thirty-five consecutive'^ in wliirh 

tincture of iodine was tlie only antiseptic used, onlv thr n cultivation 

showed th<> presence of any or>;anisms. and in each of these the Staphv- 
lococcus albus was found.' " 

The exacc details of this mode of skin preparation naturallv varv 
somewhat in different hospitals and with different surfjeons. ' It is 
however, generally agreed that it should, whenever j)ossil)le. be carried 
out before the patient is removed to the operatin<; room. By this means 
much mess and unnecessary loss of time mav be avoided.' 'j'he entire 
preparation, however, may in an iirjient be carried out with ad- 
vaiitajre in the operatinj; room. 

It the former method is decided upon, the surgeon, after carefullv 
washing and preparing his own hands, shaves the skin of the patient 
for an area considerably beyond the hniits of the proposed incision : 
should this be in the groin or the abdomen the pubes should alwavs be 
completely shaved; it is not sufficient to remove the hair from the 
side of the incision only. The shaved area is then thoroughlv washed 
with .soap and hot water for at least five minutes. A boiled liail-brush 
should be used, but not too vigorou.sly. and the dirty soap and water must 
i>e fre(|uently washed away. Soft soap mav be used, but ether soap or 
a .solution of soap in spirit is preferable.* The skin is dried as thon.ii.'hl v 
as possible with a sterilised swab and then washed over with etlier. 
When this has evaporated, tincture of iodine is freelv applied to the 
whole prepared area. Special care is directed to the umbilicus or to 
any skin fold such as the a.xilla or the firoin. The prepared area is then 
covereil with a sterilised pad or towel, which is secured in position by a 
bandajie. The patient is now ready to be transferred to thr anaesthetising 
room. Ik'fore the commencement of the operation the pad is removed 
and a final application of tincture is made.' 

When in urgent cases the entire preparation is carried out in the 
operating theatre, this proce<lure must be iiiodilie.l. In a cleanlv 
patient the .skin may be shaved with a sharj) drv nizor. and then after 
washiiif,' with ether, the iodine solution is ajiplied". If the skin is devoid 
ot hair the shaviiifr may be omitted ; if it is obviouslv dirtv it must be 
hrst scrubbed with ether soap and hot water, then thoroughiv dried with 
a sterilised pad. and finally, after treatment with ether or alcohol is 
painted over with the iodine solution. Whm septic ulcers, 
fi.itulw, or granulating surfaces are present, it is impossible to st.'rilise them 
or the adjacent .skin. The use of a nail-brush under these circumstances 
IS liable to be actually harmful, as by this means infective material may 

> .Seo lAinret. 19U. vol. 1, p. "33. 

^ M.T.''/.*','".' 'T" Tm" °- '"'"P >iK.thylatv-l spirit may Ik- \m A. Ether 

>.iturat.|tl .solution, rt surtKU'iit .,uantity ; al,„liul, .'iii i ; „il „f lav. ii.l. r, iiixx' . tliv- 

• A I per cent, .solution of jiiiric- aiiU in rfttitiod or mcthvluti'il -piiit li. > ,i|s,, I „ 

strongly recomnu n.!.;. for «tcrili«iiig the «kin. It is applii-d in th,' sa,,,,. «av as thr 

iZnirt tl'' \ ""'"A'?" cheaper and \» .said to iMn.trut,. nuuh n.oi,. 

readily to the deeper layers ol the epidermis than the iudtne solution. 



be rubbed into and thus infect tiie akin. Septic sinuses and fistula) mav 
be i.lufiLn..l with pauze. but should if poMlble be covered by 
towels or pads .luring the operation. Ma«e8 of granu at.on tissue or 
f ungating Jirowth nuiy sometimes with advantage be atenlised by the 
use of the actual cautery. „;,>„<„i 
B Prepantioa of the Operating Room. In every propeilN e.iuippe( 
hospital or nursing institution one or more r-.oms are specially constructed 
and set apart for the performance of ..perations. A modern operating 
theatre need not be described here in detail. It sl.ould however, be a 
lanre well-ventilate.l room which can be quickly heated he floor 
should be of .some material such as mosaic or concrete— not of wood-- 
which is free from cracks and joints ami can readily be cleaned The 
walls and ceiling; should be tiled, or made of some smooth material which 
will not collect dust and can easily washed. All corners and angles 
should be rounded, and there should be no ledges, cracks. ..r crevi..>s 
in which diLst can collect. Needless to say there must be no unnecessary 
furniture onlv the ..peratinj; table, smaller tables for in.struments. 
.iressin.'s; and a.uesthetic apparatus, and if desired, stools for the operator 
and the anaesthetist. These sl.ould all be constructed as simply as 
possible of metal and fllass and should be kept scrupulously clean. 

It will sometimes be impossible to move the patient, and the surjieon 
will then have to operate in a room in a private house, in tins event 
all umiecessarv articles of furniture, as well as all pictures, cur ains. 
,,Mi..-ts and -ufrs. should be removed from the room ii.ost suitable tor 
this ,„.ri.ose It is desirable that tli.'se preparations should be earned out 
on the preceding as to allow time for thorough dusting of the 
room and scrubbing" the floor. I.nmovable articles f '"'^-^J^ 
be covered over with sheets which have be.-n sprinkled xsith tJibolic 
lotion. Most modern operating rooms are provuh d with a small acljoiniiig 
,„om in which the patient is auffsthetised, and another in which the 
s„r.'eon and his assistants prepare for the operation. No one thus enters 
tlu"'"op,.rating room until he is fully prepared and is wearing a sterilised 

overall, cap. and mask. m i j t 

C Fwimition ol the Surgeon and his Assistants, The hands of 
the surgeon and his assistants are undoubtedly a very likely source of 
wound infection. Their preparation thus demands the greatest care. At 
the present day thin rubber gloves, which can be sterilised by boiling, 
are almost invariably worn. This, however, do<^not render careful 
pre,.aration ..f the hai.d^ any the less necessary Dunng the operation 
Ihe .dove mav be pricked or torn ; septic fluid will then exude through the 
puncture and infect the wound unless the hands have been thoroughly 
sterilised. Exactly the same precautions must be taken by a 1 as.sistants 
otherwise instruments, sutures, or dressings may be infected by contact 
with their septic hands. If the surgeon has any suppurating or intectn e 
lesion on the hand or fingers he ought not to operate, or it is imimssib le 
to sterilise such an area which is thus a source o great danger. 1 he uails 
should be cut as short as pos.sible to facilitate cleansing of the underlying 
irroove The skin of the hands must be kept smooth, for any roughness, 
from the repeated use of lotions or other cause, means innumerable nunute 
cracks andW'^ions in which organisms nuiv coll..ct. and which reiide 
sterilisation a matter of great difficulty or even impossibihtv. The ha ids 
should be cleaned by thoroughly scrubbing them with a boiled iiail-biush 
and hot soap and water for at least five minutes. The water must be as 



hot as possible and should flow as a coiitiniioiis stream or spray. If 
a basin is used for washing, the water should be chaufjed several tinie» 
duriiii; the eleansing process. The hands may then be rinsed in weak 
lysol and finally are immersed in an alcoholic solution of biniodide 
of mercury (1 in UYM)). The gloves, which have been rendered sterile 
by boiling for five minutes, are now ]>ut on. The surgeon then takes an 
overall, a eap and a mask, all of which have been previouslv sterilised. is opened by u nurse, and care i.s taken that 
neither the ovenill nor the surgeon's hands touch the ctlgeof this receptacle. 
Th e overall should be of sufficient length to reach to the ankles, and it 
should be provided with sleeves which are not too loose and can l)e 
buttoned at the wrist. The cufi of the glove should be turned up over the 
sleeve of the overall so that no part of the forearm or wrist is left exposed. 
Short-.sleeved overalls should not be worn, as they leave a considerable 
area of forearm uncovered which is probably imperfectly .sterilised 
and is certain to come into contact with towels or instruments. The eap, 
which ought to completely cover the Imiraiid fit fairly tightly to the head, 
may be placed on the head by an assistant. The mask, which consists of 
several layers of gauze, should cover both the nose and the mouth, and if 
the surgeon wears a moustache or beard these also. It is desirable that 
clean rubber overshoes should be worn over boots w hile in the oi)erating 
theatre. Otherwise nmd and dirt from the streets, which is swarming 
with organisms atid can easily be disseminated as dust, will certaiiilv be 
brought into the theatre. 

p. Sterilisation of Initrnmenu. Instruments should be sterilised by 
boiling them in a metal steriliser for at least five minutes, care being taken 
that the instruments are completely inmiersed. \ teaspoonful of 
ordinary washing soda may with advantage be added to each pint of 
water. This slightly raises the boiling-point and also prevents the 
iastruments rusting. Most sterilisers are provided with a perforated tray 
which may be removed and the instruments tipped into a sterilised 
dish containing carbolic lotion (1 in 20), lysol 2 percent., or boiled water, 
according to the wish of the operator. 

If there is no perforated tray, the instruments should be removed one 

one with a pair of bailed forceps. Before the operation the instru- 
ments may be arranged upon a sterilised towel spread out u})on and 
completely covering a small glass table set apart for this purpose. 
Cutting instruments are liable to be blunted by this treatment. If 
boiled they should be wrapped in gauze to prevent contact with other 
instruments, or they may be effectively sterilised by leaving them in 
carbolic lotion (1 in 20) for fifteen to thirty minutes, or in absolute 
alcohol for about the same time. Though instrutjients should not be 
iteedlessly prepared, all that are re(iuired or are likely to be recpiired 
shoidd be sterilised before the commencement of the operation : if any 
instrument is unexpectedly reijuired the process of sterilisation is apt to 
be hurrie 1 and hence imperf-ct. After the operation the instruments 
niust be carefully vva.slied and scrubbed to remove all traces of blood and 
discharge. They are then boiled and dried before being put away. 

E. SteriliMtion of Sntures and Ligatnres. Many materials have been 
employed for sutures and ligaturt i. Those in common use at the 
present day are silkworm gut aiid horsehair for the skin, and celluloid 
thread, silk, and catgut for uniting deeper structures. Michels metal 
clips are also frequently used for bringing the divided edges of the 


skin into apposition. Silver wire, thoiifjh occasioriully used for suturing 
bone, is but selduni usi'<l for approxinuitiiiK soft parts. All the abovo 
with the exception of catgut l an be sterilised bv boiling : silk, however, 
requires special precautioiui. Short lengths should be unwound from the 
wooden reels on which it is supplied and rewound on small glass reeb 
or roils, taking care that the threads are nowhere more than two or 
threi! deep. These are boiled for twenty to thirty minutes immediately 
before the operation and are then transferred to a sterilised vessel 
•■ontainiiig I in lio t arbolic or other untiseptie lotion. 

The sterilisation of catgut is a matter of nnuh greater ditfi( \dty. 
This material is made from the intestines of sheep, and though the mucous 
membrane is supposed to have been scrapeil away this is by no means 
perfectly carried out. Raw catgut is thus certain to contain many 
organisms, and unless effectively sterilised is very likely to infect wounds 
ill which it is used. It is destroyed by boiling in water, and hence other 
more complicated and lengthy means have to be employed, ("atgut has 
the great advantage that it is eventually ulhsorbcd : it is also strong, 
pliant, and easy to manipulate. Thus, in spite of dilficulties in sterilisa- 
tion, it is a favourite material for deep or buried sutures. .Most instru- 
ment makers supply catgut already sterilised in sealed tubes. If supplied 
by a good firm these are thoroughly reliable. The tubes should be 
hermetically closed ; any information as to the size of the contained 
threads or the mode of j)re{)aration shoulil be etched upon the glass : 
there should be no paper labels either within or outside. Beiore break- 
ing open the tubes their outer surface should be sterili.sed by prolonged 
immersion in an anti.septic lotion. Many methods have been suggested 
for the sterilisation of catgut. Most of these are complicated, and the 
result is often uncertain. The following are simple and effective. In 
all cases the raw Jiiaterial should first be thoroughly washed in water, and 
then soaked in ether for twelve hours to remove all grease. Mayo Robson 
recommends that catgut should be sterilised by placing the washeil 
strands in a strong metal vessel provided with a screw top containing 
xylol. This is immersed in boiling water for half an hour, at the expira- 
tion of which the catgut is transferred to a 5 per cent, solution of 
carbolic acid in alcohol. 

Moyiiihan recununcn Istliat thi'Ciitfjut.wliK'h lius been|)rcviou.slytk'iiiU'<l and wound 
on glaiM reelH, Hliould be boiled for twenty minutes in a saturated soliitionuf ainmonitini 

.sul|iliati'. the l>(iiling-j>oint of 
which is 128 ('. It is subse- 
([Uently waslscil in boiled water 
to reniovt excess of the salt, 
and is then placed in a solu- 
tion of iodofoiin 1 part, ether 
parts, in absolute alcohol 14 
parts. By either of these means 
catgut may bo raiscil to a tem- 
perature of 100° ('. or above 
without being destroyed. 
Another simple and effective 
modi' of prejuiring catgut is by 
prolonged irnniersion in a solu- 
tion of iodine: either of the 

» » I . , I followiiii; mav lie employed. 

A convenient furm of suture furceiM. ,1, , ■■ . • ' ■■ 

(l)louuie 1 ounce, potassium 

Iodide I ounce, water ."> pints. (J) Tinctuir of iodine I part, alcohol (45 per cent.) 

15 parts. In either case it should not be used until it has soaked for eight days. 



Rtmlised Hutures of all descriptions, and eApooially silk and ratftut, 

fthouttl \>c hniullod as littio an pnmhU'. The a»8i.stHnt who hns char);)' 
n( thfiii must exercise the ffrentest cnre to ensure that they do not toueh 
the outside of the vessel in wliich tliey are contained, and that the ends 
do not come into contact with any septic ohject as he hands thrm to the 
operator. Special forceps with smooth blades that will not frav the 
material (Fig. I) should be used for their manipulation, Mperially for 
keemng the thread taut during the insertion of a continuous suture. 

F. FrapmttOB ol Towcto sad Ovtnlb. A number of sterilised 
towels will be required for ever>' operation. They are arranged around 
the ini'pared area in such a way that, though this is ade(|iiatelv 
cxpo.sed. the patient and all blankets. &c., over him are completelv 
covered. .'Should the operation be in the region of the thora.v. hea<i. 
or neck, the towels mu-<t be airanged so as to shut off the ann>.sthetist 
and his apparatus from the field of operation. This may be accomplished 
by fastening a towel round the patient's neck and then raising it over 
a hoop, or, in some cases, by securing a large sterilised pad across the 
patient's face.' All towels should be securely fastened in place bv means 
of 8terili.sed clip ff)rceps. Towels and overalls should be .sterilised by 
steam under high pressure. I'nless this precaution is adopted it is found 
that the folds of the towels interfere with the due penetration and action 
of the steam. They are taken from the steriliser in air-tight cases, from 
which they are removed in the operating room by an assistant who has 
already prepared himself in the manner described above. If circum- 
stances render it inipossil)le to obtain towels sterili.sed in this way, they 
may be effectively prepared by boiling in water for half an hour. 

<t. Preparation ol Dressings, Swabs, &c. Dressings may b(> divided 
into two : (<i) those which contain no antiseptics but are sterilised 
by heat : (b) those which are impregnated with antiseptics. The former 
include gauze and pads which are made of gaingee tissue cut into squares 
of convenient sizes and enclosed between la set s of gauze. These, together 
with absorbent wool and bandages, may be sterili.sed in the .same manner 
as the towels, viz.. by steam under pressure. The latter group includes 
iodoform. sal-aliMnbroth. and cyanide gauzes. Though impregnated with 
antiseptics, these materials are liable to collect dust, and .so niav contain 
many infecting organisms. They are accordingly kept in some such 
antiseptic lotion as formalin ( 1 in .500), which soon renders them sterile. 
Immediately before use they are wrung out in sterilised water to remove 
the formalin. Sal-alembrotli and .salicylic wools are also o( '■a.sionallv 
used, but only as an outer covering for the sterilised dressings in actual 
contact with the wound. Pads and swabs, which arc use<l for sponging, 
are sterilised in the same way as the towels and dressings. Before the 
conunencement of the operation the sterilised instruments, sutures, and 
swabs may be arranged by an assistant, whose hands have been pre- 
pared and gloved, upon one or more small tables, the glass tops of 
which are completely covered by sterilised towels. 


Before conniienciiig the operation the .siirui'on should have carefully 
thought out his mode of procedure. Each assistant should have his 
particular duties assigned, and care must be taken that all instruments, 

' Sen alitu the method described for operations on the Thyroid Gland, p. 620. 


dreminKR. and other aeeeMorim which are Hkeiy to be required are quite 
roady. In this way only rati raj)i<lity and neatnew be assured. Generally 
speaiiinj;. the more t(uicklv th<' opcTafion is rompleted the better for the 

|)atipnt. though of roursf ran- and thorou^.'linp»s must not be sarrificed 
or Hp«'e(l. Careful planning and organisation are essential for success in 
nimlern surgerv. 

Tha AdmiB W^ ntt^ai of tha Anaithetie. Details 'bout the various 
kinds of aiuMthetics and theiradministration will not be given here, though 
it is desirable that the operator should havea thorough knowledge of this 
most injportant subject. Full information may be obtained from one of 

the special text-books on ana^.sthetics. Needless to siiy. the surgeon sh»)uld 
always have the fullest confidence in his anasthetist. and. at any rate 
in difficult eases, should secure the services of a skilled administrator of 
anaesthetics. Under these circum.stances the operator, after a peliniinary 
consultation, leaves the anaesthetic and its administration entirely in the 
hands of the anssthetist, who will call his attention to any unusual or 
serious symptoms which may arise during the course of the operation. 
The patient shcnild not be aiiKsthetised while he is in bed. If this be 
done, dangerous symptoms may rise wliile he is being transferred to the 
operating room. The ideal arrangement is. that he should be anaesthetised 
on the operating table in a small room, specially set apart for this purpose, 
adjoining and opening into the operating theatre. When the patient is 
anconsciouB, the table nan then be wheeled in without distracting the 
attention of the answlhetist. When this arrangement cannot be carried 
out. the patient should be ana-.sthetised either upon the table in the 
operating room or, in the case of a nervr)U8 or sensitive patient, upon 
a troHev which can easily be wheeled in and the patient then transferred 
to the table. Bandages and pads are then removed by a nurse, the towels 
are arranged in the manner already described, and the sidn receives its 
final application of tincture of iodine. 

The TMhaiqu* ot the Operation. No particular operation will be 
described here hut it will be as well in this place to give a few general 
rules and in.structions which apply to all operations. Necessary special 
instruc'ions will be given in tli ' description of cacli individual operation. 

It will first be necessary to discuss the jmsition of the ptitient durimj 
the operation. In the great majority of cases he lies flat upon his back. 
Sometimes, however, for the satisfactory exposure of the diseased parts 
some other position is required. The following are frequently employed : 

(rt) The Prone Position. The patient is here 1 -ned over so that the 
face looks downwards. One arm may be placed unaer the chest while the 
other rests along the opposite side of the body, w hid; may be supported 
by a small pillow. This position may be adopted for operations on the 
vertebral column, or in certain cases of empyemii where I < thought 
undesirable to allow the patient to rest upon the sound sidv <A his chest. 

(6) The TjOteral Position is frequently employed. Here the patient is 
turned upon his side, left or right as the circumstances of the case demand. 
The arm of the side upon which he rests is placed under the chest, while 
the legs are flexed both at the knee- and the hip-joints. This position 
may be used for some operations on the perineum or anus, for empyema 
and for kidney operations. In the latter case an air-pillow is also placed 
beneath the loin to render prominent the region of the incision. 

(c) The TrendeletAerg Position. Here the patient rests upon his back, 
but the pelvis is raised above the level of the head to a height of from 


a fi'W inrilM to as iniirh as two foot. All niodt-rii opcratiMt» l.ililfs an- 
provided with a mwhaiiism liy which the hody is casilv made to a.ssiiiiK* 
this pnetition. Tht> iittostint-s and other ahdoiniiial visrera will then tend 
to gravitutc from the peiviit towarda thf diaphrasni, thuH itrcutly fiuili- 
tatinn oprations in which a clwir view of the depth* of the pelvii* in 
di'sinihle. In an exH>»j;erut«»d Trendph'nbern position the patient will Iw 
almost vertical. If this la niiiintainod for any length of tiino, jrravi* 
disturhances of the circulation may occur, and the continued pressure of 
the vist'cra upon the dia(ihra;!n may seriously emharrass the action of the 
heart when that orfian is not |)erfectly liealthv. 

(d) In other opi'rutiohs. u|M>n the nall-hladder for instance, it mav Im* 
deitirabje to displaco the intt'stines from the upper part of the ahdomen 
and cause them to jinivitate towarda the pelvia. This may he cfltH te*! by 
tilting the operating table so that the head and the upper part of the 
trunk are at a hii;her level than the pelvis. 

(<■) Tlw LllhotDhiif I'o.sitliiii is essential for most operations upon the 
rectum or the nerineuni. This may he conveniently arran;;ed either l>y 
means of a Clover's crutch, or by n>stinf( the |mtient's hams upon two 
adjustable vertical supports attached to the lower end of the operating 

( f) For .special operations the affected part may be steadied or raised by 

means of sand-l)a<;s or |)illows pla< ('i! heneat li the towels, as has been seen 
in the of the kidney. .\lso in operations upon the pdl-liladder a 
small cushion beneath the hiwer part of the thorax throws the liver 
forward and thus renders both the ducts and the jjall-bladder it.self much 
more prominent and easily accessible. For opi'ratioiis ujxin the hand 
or fingers the arm may often with advantage be abducted and allowed 
to rest upon a small table at the side of the operating table. As a 
>;eneral rule the patient shouhl be ana'sthetised in the dorsal position and 
then be placed in the si)ecial jjosition recpiired for the operation. 

The skin incision should be carefully plamied so as to f;ive a f;ood view 
of the deeper parts anil at the .same time to avoiil important structures. 
If the incision has to be made in the neighbourhood of larfje vessels or 
nerves, it should always be nmile pa ra I le| to and not across them. W hene ver 
possible, the incision, especially if upon the face, neck, or other expo.seel 
part of the body, should follow the line of natural folds or creases of the 
skin. In this way subseijuent disfij.'urenient is minimised and the resultini; 
.scar, if the wound heals hy primary union, will be a .>>.'arcely noticealile 
white line. An excellent example of this i.s the remarkably small 
deformity after excision of the upper jaw where tin? incision follows the 
natural folds at the side ol the nose and beneath the lower eyelid. To 
ensure healing by primary union, the skin shoidd be clean cut with a sharp 
knife, avoidinfjall lacerations and irrej;ulaiities. Care should be taken 
that the incision is not too short : a loni;skin incision does not. for in.stance. 
weaken the abdominal wall, and the more thorough e.xposure of deep parts 
freijuentlv enables the operation to be cotnpleted with less injury to these 
more important structures. Similar rules are to be followed in the divisicm 
of deeper structures. When the deep fascia is reached it should, before 
it is divided, be fully exposed by separating the superficial fascia and the 
skin on each side with a few touches of the knife. All aponeurotic and 
fascial layers slunild be divided by cieati-cul incisions. Muscles ou^ht 
if pos.sible to be drawn to one side : if this is impracticable, their fibres 
should be separated by some blunt instrument, after the sheath has been 


op»n«d, nther than be divided bjr the knife! Thor< howcvor. in the 
gnat nuijorityof CMee no naaon whjr • nuKle ■hould not >m> cut nrroM, 
provided that tiM cut enda are identified and mibMOiiufiitly carofiilly 
unitml hy suturp«. These points are illuHtratcd l>y twf> i>f the rdniiiioii 
niethmlH of o{H>nin); the niMlomen. Separution of iniisciilar fihres i« often 
uimhJ in the " innsrlc-splittinji" niethotl of o|M'nin); theahdoinen in tlie 
operation of appendireetoniy. Another inethiHi whieh also iiitliets hut 
litth' (hinia)(e is to incise the anterior layer of the rectUH xheath. retract 
the rectus muscle, and then incise the posterior layer of the sheath. The 
greatest care must be taken to avoid unneceaaary injury to hirge vessels. 
Kmaller vessels should be seenred between two pairs of Rpencer Wells 
forceps and then divided. 

It is of even greater importance to avoid injury to nervi'n. Division 
of a larj;c nervi'-trunk is a serious nuitter. for it will irrtainly lead tu para- 
lysis and muscular atrophy, which in spite of suture may l>e permanent. 
Division of smaller muscular nerves should also be avoided, for such an 
injury will result not only in partial at complete paralysis of that muscle, 
but also atrophy, which tocher may cause considerable dii^gurement 
and disability. 

.\t the r •nclu^'io'i of tJ' ' operation all hir»inrrliiiifc iiiiisl be stopf>cd. 
Kach hleedinji-piMiit in the course of the operatiuii is sccup-,! hv Sp'-iircr 
Wells forceps, care heinj; taken as far as p(wsil)le to clip the hleedinn 
vessel alone without takinj; up masses of surrountlinp ti.ssue. Small 
superficial vessels will he probably quickly occluded. Small or mediuni- 
sizied arterial may be sealed by torsion, care being taken to give the 
vessels six or seven half-twists and not to twist the forceps coniplctelv 

Other vessels will recjuire to be lijratured with tine cat^'iit. (icneral 
oozing may be checked l)y irrigating with sterilised saline solution at a 
temperature of I'M)^ ¥. Deep st uctures should be closed in layers. 

^ the divided edges being accurately lm>ught together. For instance. 

' in abdominal operations separate layers of sutures are used for the 
peritoneum and for each muscle or aponeurosis that has been divided, 
('ontinuous sutures of silk or catgut are employed, or celluloid thread 
if a stronger material is recjuired. The cut edges of the skin are united 
by continuous or interrupted sutures of horsehair or silkworm-gut. or 
Michel's m-«tal clips may be employed. Care be taken that the 
edges of the skin are not turned in. SliouM this occur, epithelial surfaces 
are held in contact instead of the raw edges, with the result that when the 
stitches are removed some gaping will take olace. leaving a small area 
which has to heal by uranulatioi\. Special care to secure accurate 
apposition must be taken when the incision is on the face or neck. 

The (pu'stion of drainage fre(juently demands careful consideration. 
If the operation is essentially septic, for instance opening an appeixbcular 
abscess, drainage is certainly necessary. When, however, the operation 
is aseptic, but a large cavity in which blood and serous exudation can 
collect is necessarily left, drainage is still often desirable, otherwise the 
cavity will probably fill up with blood-clot and coagulated exudation, 
which form an admirable medium for the growth and multiplication of 
organisms. A few cocci of a not very virulent type which would soon be 
destroyed by healthy living tissues may easily iiifect and cause suppura- 
tion in such an inert mass. 

When such a space exists, as in the axilla after the removal of the 


hroiiHt iind uxillarv nmtrntM for rarrinnnw. or tiio i«rn>tuiii aftiT a rixliciil 
cure for hydrocele, it ia beat to inaert a anwll drHimi).'!' tulx' to hIIuw auch 
exndatinn to eampe. Thmiffh mtrh a wound may apiM-ar |M>rf<><'tlv <)r>' 

ami fri'v from I>I<kmI at th<' ttTiiiiiiatioii of thiMipi-ration. it i.^aliinMt riTtaiii 
that Hi>m<' "oziiiji will iK'ciir a.s the cfTi'ct of tin- aiia'stlictic is pas.tiiij! i>|T. 
A riil)l)<'r ilraiiiap' tiiii'' may \tnM to the ilff|M>r parts of tlx- wmiiihI 
iM'twcfii the stitclir. . or tlii> original woiiinl may Ih> ciimpli'tflv rlnscil ami 
the tiilM' iiisfrtril tlirou);li a small Htali woiiml in rlo^o |)ro.viriiit . to it. 
This niothod ullowa ilruiimKC to take place and the wound to heal rum* 
p|pt«'ly -a point of frreat importance where the abdominal wall has been 
divided, as in an operation for at iitt- appendicitis. Fur driiihiiijj a larjie 
suppuratin>» cavity, several lateral holes ithould he cut iti the tiihe or a 
layer of piiize may he wrapped round if. Ktlicient draiiiai/e mav also he 
securetl hy cuftinj; the tid>e open and in.sertinj; a wiek of rihhon yaii/e. 
For «n>aller cavities one or more strips of pm/.i' may he employed, wliile 
Hinall Huperticiul woiukU may \}e drained by imtertiiin a few MtraudH of 
8ilkworin-);nt iK'twoen the stitchea. If a drain in employe«l in an aneptir 
wound to allow the escape of bloml an<l senim. it may be removed at the 
end of forty-eijrht hours and then will in ali |)rohahility not have to he 

After-treatment of the Wound. This will de|)end npon the aseptic 
or septic character of the operation and whether drainage has hi-eii 
necesnary. An aseptic wontid which ha.- been conipletoly and carefully 
cliiBed will heal hy primary union ; under these circuniMtances the 
temperature and the pulae will remain normal, and when the patient 
has recoveretl from the effects of the annfsthetic there will be no 
constitutional disturbance. An aseptic wound should he painless or 
nearly .so. since iiiHammation is the most common cause of pain in a wound. 
I niess the dreasinps or hauda<;es reipiire re-adjustment, such a wound 
need not he dressed until the stitches are removed, which is u.sually done 
between the eighth and the tenth days. All dretminfts must be carried 
out with strict aseptic precautions, the drcs-^er must carefully prepare 
his hands, and all instruments. dre.s.sini;s. and towels are sterilised as 
carefully and thonnijjhly as at the original operation, a.septic wound 
is. when the dressiiii; is removed, dry and free from all redness, swelling, 
and imluration. 

.V septic wound will recpiire more fii i|uent dressing, usually every day, 
or if fomentations are u.sed. these ouj;ht to he rhanged every four hours. 
If a drainage-tube has been used, the time of its removal will to a great 
extent depend upon the situation and cause of the suppuration. If super- 
ficial it may he removed at the end of forty-eijrht hours, and after cleansinj; 
ami hoiliii}! he replaced. If the septic focus is deep, as in acute -ippendi.x 
or gall-bladder cases for instance, it may he left in situ for three or four 
days or even longer. In either at suhse(|uent dressings it should he 
gradually shortened, and. as the wound closes, a smaller tube should he 
substituted. When the suppura* diminishes the tube is omitted and a 
gauze drain used in its place. 

Treatment of a Wound which has becom* levtic. Occasionally, in 
spite of all precautions, the wound may become infected and suppurates. 
I'sually this points to some failure in the preliminary preparations : .sorne- 
tinu-.s, however, it is due to the drcs-sings becoming soiled or displaced, or 
they may be disturbed either consciotisly or unconsciously by the patient. 
When infection does occur, it is great importance that the septic nature 


of tlu> wound shall Ih- rocofiiiis.Ml and trcatod a.s soon as possible. (Hher- 
wis." til." septic process inav extend deeplv in and around the wmiiKt. and 
even invade the vessels and ivmphatics. The most inip<.rtant infonnation 
as to the occurrence of sepsik is aflortied by the temperature chart, which 
should he carefiillv watched after every operation. A slight rise ot 
teiiipcrature (<•;) or K O ) is not infref|uentlv noticed immediately after 
operations which run a perfectlv aseptic cr.urse. and lience need cause no 
anxietv. A more coiisiderahle (up to l(f.'^) on the second or third 
evening is. however, of more serious import and should h ad to an 
immediate and careful examination of the wound. When siii)puration 
occurs, pain is usuallv experienced in the repion of the wountl. Its 
intensitv varies jxreatlv. It mav be very severe and throbbing in character, 
but on the other hand it mav he entirelv absent or the patient may com- 
i)laiii of discomfort oiilv. in the latter case, or^'anisms of comparativelv 
slight virulence, such as the Staphvlocoinis allnis. have jirobably infected 
a collection of effused i)i(M)d. In these too. there mav be littleor 
no pyrexia. If sepsis is suspected the woiin.l must at once be inspected. 
The dressing must be carried out with the same i)recautions and care as 
in the of a clean wound. The reason for this is tliat infection may be 
due to comiiarativelv harmless organisms : the tissues are. however, in 
the most favourable condition for the jxiowth of any organism, and hence 
tiie greatest care must be taken not to introduce any of a more virulent 
tvpe? .V septic wound will appear swollen, red. and (edematous ; jMis may 
also be exuding from the incision or .stitch hoU's. Sufficient sutures 
be removed to release all tension and to open the wound .sufficiently to 
ensure a free exit for all pud and discharge. If necessary one or more ad- 
ditional incisions must be made to provide free drainage. The wound 
mav then be ■'eiitlv swabl)ed out with sterilised .saline solution or dilute 
antiseptics such as carbolic lotion (1 in (iO) or hydrogen pero.xide 
10 per cent. Strong antise|)tic lotions should not be usc<l. These cannot 
destroy all the organisms present, and are likely to damM^e the tissues and 
thus hinder their normal reaction the invading bacteria and 
their toxins. The wound must now be drained ; its situation and depth 
will enable the surgeon to decide as to whether rubber drainage-tubes 

or .'auze sliould 1 mploved. .\ dressing of antiseptic gauze (cyanide, 

iodofonn or should then be ai)plied. If the inflammation 
is acute, hot fomentations mav be used witli advantage. Several layers 
of lint wrung out of hot boracic lotion or percliloriih' of mercury ( I m foi Kl) 
may be used for this purpose. To obtain tiio maximum amount of i)enetit. 
the fomentation must be applied as hot as possible and be changed fre- 
(|iieiitlv. Pain is relieved l)v the heat, pus and toxic materials are readily 
<liscliarg.'d. and the antiseptic liiiiders the growth of the infecting organ- 
isms. Should the wound be in the arm or leg. immersion of thelimbma 
metal bath containing hot boracic or other ioti> n mav often be carried out 
with advantage. The lotion in the Ijath must be kept hot and clean ; this 
may be ensured by allowing a continuous stream of hot lotion to flow 
slowlv through the bath. 

Constitutional svmptoms may be severe, and hence general treatment 
is of great importance. The .strength of the patient must, in severe 
cases, be maintained 1)V frei|uent administration of small quantities 
of suitable nourishment, and alcohol, preferably in the form of small 
doses of brandy, may also be of service. Free and n-gular action of the 
bowels must aUo be secured. When the wound is opened up, a specimen 


of the pus should 1.. collected on a sterile swal) for cxiiiiiiiiiitiiui niiil 
idi'iititicatioti of tlie infecting organism. Should signs of septica-niia 
iiljpt'iir or sliouid the condition of tht- wound not (|uickly improve under 
the above treatment, a suitable serum (antistreptococcic or antistaphylo- 
coccic) mav then be injected if tiie cause o£ the infection is known. Or, 
if thoiifjht desirable, a vaccine may be prepared by the bacteriologist 
from the actual organism. 

General Atter-tnatment. At the termination of the operation the 
])aticnt is likely to be eol<i as the result of the necessary exposure, and 
after a prolonjied or severe ojieration to be to some extent in a state of 
shock or colhipsc. lie should tiiercfore be (juickly nMiiovcd to bed 
and kept wurin with the help of hot-water bottles and blanki'ts. lie is 
usually placed at first flat upon his back : some one imM be at hand 
to turn the head to one side and draw the jaw forwards in the event of 
vomiting occurring, otherwise vomited material may be drawn down 
into the larynx or the lungs. There is. however, no reason after most 
operations why the patient should not be propped up on one side, which 
is more comfortable and renders tiie iidiaiation of rei;iir<;itatc(l material 
less likelv. Later, after recovery from the etfects of the anaesthetic, 
he ay. according to the nature and the .situation of the operation, be 
kept jj) the dorsal posititm. be propped on his side (lateral position), or 
turned upon his face (prone position). Elderly patients, and those 
suffering from general peritonitis, may often with great advantage be 
propped up in the .semi-recund)ent (Fowler's) position. This, in the 
latter, aids the drainage of pus to the lower jmrf of the abdomen, and in 
the former throws less strain upon the action of the heart and lung's. 

Shock. Shock is a condition of the greatest importance to the sur>;eon 
for it frequently occurs, and is a common cause of death after .severe 
operations. Much excellent work has been done in recer.t years with 
reference to its nature, catise, prevention, and treatment, but a great 
deal still remains to be done. Shock may be defined as a condition 
produced bv injury in which the action of the vital orfrans is seiio\isly 
depressed. A brief outline of the mechanism of its production is all that 
can be given here.' When shock occurs there is always a <;reat fall in 
blood-pressure. This has been shown by ('rile to be due to dilatation of the 
splanchnic veins. This leads to the withdrawal of so much blood from 
the systemic circulation that the blood pressure is greatly reducetl. 
(Vile has further shown that the fall in blood pressure is not due to cardiac 
failure, but to exhaustion of the centre. .\t first the fall in 
pressure may be rectified to a certain extent by the iiicn ased activity 
of the vaso-motor mechanism and increa.sed action of the heart. Kventu- 
ally, however, as the result of repeated violent afferent stimuli, the 
vaso-motor centre becomes exhausted, with the result that there is a 
still greater fall in blood [)ressure and the bl<K)d collects in the large venous 
trunks generallv. The heart is now. owing to the small amount of blood 

1 For further iiildrniiitiuii mi llii.-* sulijict rifcTcuci' nmy lie iiiaiU" to tlir fclldHiiif; 
lUlKTu and lectures: (}. \V. ( rile, "An £x|ieriiui-nt»l Kes»-ar»li into .Siirjjicttl SliiK kiiml 
( olla|)M< (Tmn>>. Cofl. Phi». Vhiluihl . lOOI. vol. x.\iii. pp. .")n-82); I*. 1.. .Miinuiicrv atnl 
W.L. Svnios. "The S|MH jfic Cravity of the Uloodiii Shoi k " [Trm^ Vlni^id . Sue.. MIOT. 
p l.">) ; 1'. I.. Miininicrv. ' Hiiincrian l.i'cturi s on th( Tri'atnu nt of Shoe k ami I 'olla|isi- " 
{hinrd. vol. i. pp. (>!!•>. TTti. ami S4(i; ; H. ( ii-hinj;. •'Oil the .Vvoidanif of .SIkk k 

in Major .Amputations liv ( iH ainisation of th.' i. iil'i- Xeivr 'I runks preliminary to their 
Division" {Tram. Mtd.'S<jf. II l!<C-i. p. ;ftU ; H. Tynrl tJray .ttjd I.. I'arxonx 
{Brit. Mei. Joum., 1912, vol. i. pp. 038, 1004, <U4id, 1 120). 


brought to it. unable to efficiently carry on tho ciri ulntion. oven though 
for a time it attempts to do so by more forcible a iid rapid action. Sooner 
or lator tho lioart svill become exhausted and death then occurs, or 
insullicicnt Moot! niav be supplied to the vntal centres in the mednlla 
with tho sanio rosiilt. Tho ossontial thiiif; in shook is thus a fjroat fall in 
bh)0(l piossuro hroufiht about by faiiuio of tho vaso-inotor nioohanisiu 
caused bv oxliaustion of tho vaso-uiotor oontro owiui; to lopoatod violont 
afferent stiuuili. Shock may follow any sovoro injury or oporation, but 
is especiallv likolv to occur if the thoracic or abdominal visoora. tho testicle 
or urothra" is involved. With regard to abdominal operations, shock is 
most likolv to bo .severe when the viscera in the neighbourhood of the 
solar ploxus, cspociallv tho duodoinmi and stoniaoh. aro intorforod with. 

Collapse is a oondition closoly alliod to shook, from which it cannot 
always bo distin<;uishod : iiulooil, tho two may occur to>;othor or shock 
may follow collapse. Collapse is also associated with a low blood i)rossuro. 
but Crile regards this as due to inhibition of tho vaso-motorc vhich 
is tho essential distinction from shock. It may be brougli . by 

sudden loss of a larpo (piantity of blood or by mental imi ■ or 
violont afToront impuKsos may produce a suddoii iidiil>ition of th. lontres. 

Symptoms o! Shock. Thoonsot is usually suddon. tiioufiti by no moans 
always so. The pulse is rapid, weak, of vory small volunio. and may bo 
irregular. The respirations aro shallow antl occasionally show tho 
Cheyne-Stokes rhvthm. Tho suifaco of the skin is cold and pallid, and 
tho "temporature is subnormal. There is great muscular relaxation and 
woaknoss. and though consciousness is not lost the mental faculties are 
dull. The pupils are moderately dilated and their reaction to light is 

Prevention o! ttioek. Prophylactic moastnos aro osi)ocially auwd 
for in all cases where, from the nature of the oporation or tho con- 
dition of the patient, shock is likely to occur. Most important is a 
thorough preliminary examination, especially of the kidneys, and 
careful preparation extending if necessarj- over several days, during 
which tho patient is got into as good condition as possible, and 
attention is directed to tho treatment of any visceral ilisoase. fare 
must be taken that tho patient is kept warm during the operation, which 
is completed as rapidly as possible, and that lie is then .piickly roturno.l to 
bed. where hot bottles and blankets are n.sod to guard chill. 

It has been pointed out that shock is prfKlnced by the effect of violent 
afferent stimuli on the vaso-motor centre. Any means of preventing or 
diminishing stimuli will thus bo of service. For this reason an 
injection of morphia (I.. M.H. gr. J) mav with advantage bo given about 
twontv minutes before the conimoncomonr of the ana>sthe-i i. Crilo insists 
on the importance of the injection of coi aino into tho largo norvo trunks 
which supply the region of the operation. Tho elVoct of this is to block 
the transmission of sensory impulses and thus to les.sen the likelihood of 
shock. Spinal amosthesia" also will have the effect of blocking afferent 
impulses, and mav therefore bo chosen in cases which are in other respects 
suitable in which severe shock is anticipated. Tho importance of this is 
emphasised bv Tvrrol Urav and Parsons (7.!-.). 

The question" often arises as to the desirability of operating upon a 
patient who is already in a state of shock or collapse, the result of some 
severe injury or acute disease. No invariable rule can be given ; each 
individual case must be considered upon it« merits. If when a patient 



is first seen, after a seven' railway crush nf the !e<; or with acute p'ueral 
peritonitis for e.xaiiiplc. it is thought that the pulse and general condition 
may possiblv improve, it will be well to allow an interval of some hours 
to elai)se while he is kept warm, infused, and treated with stimulating 
nutrient enemata. Should it on the other hand be considered that 
improvement is unlikely to ensue, innuediate operation gives the only 
c hance, though |)ossibly a taint om*. of success. 

Tnatment of Shock. .\ patient suffering from shock should always 
be kept warm bv the use of hot bottles and blankets ; the foot oi the bed 
should be raised so that the head is l(»wer than the feet. Stinmlants and 
other druf.'s administered by the mouth are of littltMise. for their absorption 
by the stomach is unlikely! Hot and stimulating' mitrient enenmtii may. 
however, be emph)yc'l with advanta^te. Thi'V should be administered 
through a tube introduced as far into the bowel as possible. Strychnine 
and other .stinmlants. whether given by the mouth or hypodermically, 
are useless in shcK-k though they may be of service in collapse. In the 
former condition they only stimulate the heart when that organ is already 
making increased efforts to maintain the circulaticm with the diminished 
.|uaiitity of blood at its disposal. Thus, though stimulants may tem- 
porarilv improve the pulse, they soon increase the tendency to cardiac 

Crile points out that in shock there is a deficiency in the output of 
the heart owing to the stagnation of the blood in the large veins brought 
about bv the failure of the vaso-motor mechanism. He suggests, 
therefore, that the treatment should be directed to supplying the heart 
with additional fluid to compensate for the diminished intake, and to 
restore that jxMipheral resistance which has been lost as the result of the 
vaso-motor failure. The first of these is effected by infusion, the second 
bv mechanical means and by the use of adreiuilin. 

Infusion is best carried out by allowing sterilised physiological saline 
solution to flow through a cannula which has been inserted into u vein, 
usually the median basilic. It may also be given subcutaneously. when 
the needle is usually inserted beneath the deep fascia into the loose tissues 
of the axilla, or by nutans of repeated or continuous rectal injections. 
The first method is. however, best. With a view to causing contraction 
of the small arteries ami thus increasing the peripheral re.sistaiu'e. he 
suggests the addition of adrenalin to the saline solution. As this is rapidly 
oxidised by the tissues he advises its continuous administration by 
adding sufficient adrenalin hvdrochloride to the saline to make a solution 
of 1 in oO.OfK) or I in l(Hr(HK) (."j adrenalin to 1 pint of saline). 

The circulation may be improved mechanically by gentle abdominal 
mas.sage and by firmly bandaging the abdomen and limbs over a layer of 
( otton-wool. I'are nuist be taken that respiration is not impeded and 
that the bandages do not in any other waj; inconvenience the patient. 
Inhalations of oxygen may often be given with advantage, and Lockhart 
Mununerv advises gentle artificial respiration which does good by drawing 
blood into the large veins w hich open into the heart and by increasing the 
oxvgenatiou of the blood. Injections of atropine may also be good. If a 
patient remains in a condition of shock for some considerable time, plenty 
of fluid should be given by the mouth, and in these circumstances it may 
be necessary to give nutrient enemata. Should severe symptoms of shock 
appear during the operation, it should be completed as rapidly as possible 
or if thought desirable abandoned. 


iMdiilK. The question of feeding after an operation, though naturullv 
of great importance, will depend upon the age and actual condition of the 
patient, the duration of the a.Kestheiii, and the nature of the operation. 
A few g.-iieral rules and instructions may, however, be Pven. After an 
operation of anv magnitude the patient usually re.,uires but little food. 
The thing is to give plenty of fluid, either bv the mouth. »)>;.'" "^I""; «r by 
saline enemata After a comparatively slight operation a little light food 
such as a cup of weak tea and a little bread and butter, may be allowed a 
the end of six or eight hours, provided that there is no vomiting and that 
the patient feels inclined to take it. After abdominal or other .severe 
operations, small ,,uantities of hot water may be given a* frequent 
intervals during the twent v-four h..urs. At the end of that time, fluid 
nourishment may be allowed at regular intervals in gradually increasing 
quantities. Milk is often given, but is l)y no means es.sential. Some 
patients are unable to assimilate it, and it may cause flatulence and thus 
lead to much discomfort. There are a number of fluid foods^ some of 
which are partially digested, prepared by well-known firms, which may 
be n.sed with advantage: while chicken or mutton broth, or even light 
solid food, mav be alloNved in suitable cases. After the bowels have acted 
the nature and variety of food are gradually increased, until the patient 
is on ordinary diet, care being taken that all nourishment is light and 
easily digestible. The feeding of old people and of young children demands 
cl )se attention. The former are liable to suffer from exhaustion and 
hence small fluid feeds should be started as soon as possible. The latter 
are liable to be upset bv anv change of diet, uni hence should be given 
the food to which thev have been accustomed as soon as they have re- 
covered from the anesthetic. Should vomiting persist, or should feeds 
cause nausea, nutrient enemata may be desirable in these patients. 

In most cases it is advisable that the bowels should act on the second 
or third day. It is sometimes desirable that the action should occur even 
earlier, while occasionally --after operations on the rectum for instance-- 
it may be necessary to" keep the bowels confined for a longer period. 
Drastic or irritating purgatives ought to be avoided. especiaUy when 
exhaustion is present. As a general rule an ounce of castor oil is a 
satisfactory aperient for an adult. This ma>- be followed by a soap ajid 
water enema, or an oil enema composed of castor oil 5"J and olive oil 311] 
mav be tried. Another useful method of getting the bowels to act is to give 
small of a saline purge, such as Mag. Sulph. .^ij, at intervals of an 
hour until an action occurs. Small doses of calomel repeated hourlv are 
sometimes employed, but it must be remembered that this drug, it not 
quickly successful, mav set up a serious and troublesome colitis. 

Vomiting. This is "a very common and troublesome post-; ;i esthetic 
complication. It may occur after any general ana-sthetic. even after 
nitrous oxide, but is especially prone to occur after ether or chlomtorm. 
It is more common after the former, but the more senous cases of per- 
sistent vomiting usually occur when the latter has been employed. In 
either case it is far less'likelv to be troublesome if the patient hw been 
carefully prepared and the stomach is empty at the time of the admims- 
t-ation." Vomiting after the use of ether appears to be due to the presence 
of the drug in the stomach, since the vomited material consists of thick 
mucus with a strong ethereal odour. This ether is to a great extent swal- 
lowed with saliva, but there is also considerable evndcnce to show that 
this drug is also excreted by the gastric mucoua membiane. Vomiting w 


also often caused after cperations on tlu- nos.-. moutli. and throat by the 

nr.'sence of swallowed blood in the patient s stoiuarli 

' Joltini;. or other disturbance after the operat...... .s .. so verv hable 

t„ start vo...itintr : tl,- t.ati.M.t sl...ul.l thus b.- transferred froni the oper- 
ti^^^tlble to hi; b..a J .......tly .„.d ,entlv as possible. If the 

.l«,es not cease after a few l.onrs s.m.u-,,.-nt l.e,..,mes necessary. A 
J^^ple and effe. tive is to ,ivo half a ,M..t ol hot water. Th 
will probablv cause in.n.e.liate^'. but t washing' of the 
sto.u!u i, thus brought about is likely to ren.ove the eause of the trm. 
iii. arhonate of soda grs. xv may with advantage be dissi.lve.l ... 1 1..- « a , . 
\u troublesoi..- cas.-s it ...ay be necessary to pass a soft t..l.e a..a 

thorouiihlv wash o\it the stomach. .. ... 

H t troufi cortVe is su,..eti..,es ..tfe. tiv.. i.. sto,.,„ng vcun^Ug. wh.h« 
in other case.Ca little is ....i. klv s-.- eesslul. Sn.a 1 doses of 

tinctureof iodine, liy or Hlij in T.ij "f Hot water, ve„ hoiirly for fo... . t, 

hours is often verv efTective in obstinate cases. Hewitt recon.n.e.,.ls a., 
eiema of Pot. Broni. grs. xx dissolved in water Jij for persistent 
in neurotic i.atieiits. ■ 

Retention of Urine. This is by n.. means an se.,u. la. 
It inavoccur both in ...e.. au.l wo,,,.-,, alt,.ral.<lo,„mal operatums. but s 
particularlv cou.nio.. after operations on the peiiu.-uni. '•X* ';' n 

^morrhoids. and the pelvic organs: .t .s a fre.,uent at.on 
SS^Jerations for hernia and varicx^ele. This rc e.U.on ,s 
usuallv regarded as reflex in origin. In some cases »I'l'';i''-;:/;;J " 'Z" , 
to anwiUingness on the part of the patient to make the effort owing to 
1 e pain or ciisc.....fort of Ihe necessary strain. In other cases the presenc. 

of dressings and ba.idages m.'chanically render micturition a matter o* 
diflicultv. especially if the bladder has been allowe.l o become over- 
distended. Lastly: when the .etention ,.ersists lor .some .lays, the neurotic 
element is probably an important factor m Its causation. 

The unne should be drawn off by a carefully stenhsed soft rub!..', 
catheter. Should this be necessary on more than one oi-casio... chang.' 
of position n.ay be successful in terminating the trouble. A mal^f 
ean be r..lled over on to his side, while a female should be pi ?ped up m 
the sitting posture. t fi,„ 

Pulmonary Complications. These are usually a se,,..ela of the 
thetic rather than of the operation : thov ".ore re.p.entiy ah.^^ 
ether. Bronchitis is the commonest trouble ; it is most likel) t. o.< u 
in patients who are predisposed to this disease. In rare cases a typical 
attack of lobar pneumo.iia may occur-the so-called ' ether pneuino ma. 
In other cases inl.alatio.i of particles of yoniit. blood-clot, or septic material 
from the mouth ..r upper air-passages n.ay set uj, a broncho-pneumc^ 
There is no doubt, however, that many ••ases regarde. as P > " ; 
pleurisy are really the result of infarction {mh- mira). In elderl.N I'^tu n s 
the bases of the lungs, where the circulation is likely t.. be unpaired ovvu.g 
to the recumbent position and the action of gravity, n.ay I'/'J"'"'' ' " 
gested and eventually consolidated-a process known as « 
pneumonia." This complication, which .s ..ft.Mi fatal, is best a^uded bj 
getting these patie.its up as soon as and by keeping them wel 
propped up during the iieces.sary stay i.. b.-l. whe,. von .t ..g 

has b^n excessive the patient may complain ..f a s.-vere pan. ... t'';-' ' 

part of the chest. This is muscular in origm. and due t-' 

strain but its situation and occurrence when a deep breath us taken nidv 



suggest the existence of pleurisy. In rare cases where there is some latent 

tuberculous trouble at the apices the administration of an anaesthetic may 
be followed bv ol)\-ious signs and symptoms of phthisis which uuiy not 
have been previously suspected. 

Thrombosis and Embolism. These are both conditions of great 
gravity which occasionally occur after operations : the latter, which is 
always preceded by the former, may leatl to sudden death without any 
premonitory symptoms. Thrombosis is most likely after operations 
upon the abdominal or pelvic organs. The coagulation may take place 
at the site of the o[)eration. but often occurs in the left femoral vein 
though the field of operation may be some di.-^tance away- an ai)penili- 
cectomy for instance. The cause of the thrombosis is often uncertain. 
Some cases are undoubtedly due to sep.sis. but in the majority not only 
does the clotting take place at some distance, but the wound heals by 
primary union and shows no evidence of infection. Any of the following 
conditions may play an important part in its causation. 

{a) Thrombosis is likely to occur after prolonged operations upon 
ana>mic patients or those suffering from some wasting di.sease. (/>) When 
excessive ha'inorrhage has occurreil either before or during the operation, 
(c) Traumatism either by contusion of the wall of the vein by rough 
manipulation or traction, or by the application of a ligature to a small 
vein close to its junction with a large venous trunk, (rf) Tight bandaging, 
especially a spica bandage which may press upon the femoral or the 
internal saphenous vii:<s in the groin, {e) Prolonged rest upon the 
back after an operation, especially if the legs are flexed and kept at rest 
by a large knee pillow. (/) A prolonged milk diet is stated to cause 
an increase of calcium salts in the fSasma and thus to increase the 
coagulability of the blood. 

The interval between the operation and the onset of the thrombosis 
varies from a few days to a few weeks. In a series of 66 cases collected by 
R. G. Anderson * the average interval was 13-3 days. The onset is 
generally sudden, though as a rule for some days before the occurrence of 
any local symptoms there is slight pyrexia aiui some malaise. The patient 
then complains of more or less severe pain in the leg. On examination 
the limb is found to be swollen and tender, especially along the course 
of the affected venous trunks, which i.iay be palpable as hard cords. 
Later the oedema increases and the limb will then pit on pressure. The 
great danger of thrombosis is that the clot may become detached ; it 
will then be eventually carried by the blood stream to the pulnumary 
artery, when it must produce pulmonary embolism - or infarction of the 
lung. Displacement of the clot is likely to be brought about by some 
sudden movement or exertion. The patient must therefore, when 
thrombosis is known to have occurred, be kept at rest until the clot is 
firmly adherent to the wall of the vein. This will take from two to 
three weeks in aseptic cases ; but when the thrombosis is of septic origin 
a longer period is recjuired. since there is considerable danger of embolism 
occurring during the process of softening of the clot. 

The affected limb, which should be kept slightly raised on a pillow, 
may be loosely bandaged over cotton- wool. 

Sandbags may be used to steady the leg, but splints and tight bandages 

1 flue's IIosp. Oazetti , Now Serii'S, vol. xi.x, j). 90. 

' Ilcfcronco may bo made to a paper by LouU Blaachard Wilson on " I-'atai I'ost- 
opention EinboUMi " {Ann. efSurg., 1912, voL Ivi, p. SOB). 


Klimild hf aviiiilt'tl. Tin- |>iitifiit imist tuld ul tli.' n.cissity of re- 
fraining from all movenient. Purpitivt'sshmiid iii)t lie jjivcii. liut n-fjuliir 
action of the bow»>ls must Ik* (•nsurod by niram of pneniuta. After a 
few weeks the swelling; \isiially disappenis mid the circulation i« completely 
icstoreil. fii tlie event r)f the s\velliM<; iiersistinj.'. massage will he of 
service. l)iit this iiietlind of Ireatiiient iiiiist of course only be eniploy<Ml 
ill tlie later sta^'i'Siiiid even then with caution. 

Embolism usually occurs after .some movement or e.xertion. often of 
a very trifling nature such as sitting uj) or turning over in bed. The 
])it ceding thnmibosis may have taken place in .some deep veswl without 
anv si>.'iis or svmptoms and tlius may have been entirely imnn'ogniatHl. 
The sudden unexpected death which may then take place in a convalescent 
patient who is ai>pari'ntly out of daiiL'er after tin' operation is oni' of tint 
most terril)h' accidi'iits in suiireiy. Shoiilil the clot he ol su< li si/.e as to 
block either the whole |(ulinoMaiy artery or one of its main Inanches. 
iLsuallv the left, death will almost certainly occur. Should, however, the 
clot besnuill enough to be carried into one of the smaller terminal branches, 
the patient mav recover. In is event physical examination of the chest 
a few (lavs later will probabl\ -veal an area of solid lung and a patch of 

VVlieii embolism occurs the patient is suildenly seized with a 
licute pain in his ciiest ami at once becomes collapsed. There is 
verv severe and distressing <lyspii(ea : the pulse is tecMe. Ilutter- 
iiig, and very rapid ( 12(1- l<><i). The face is cyanoscd. and sulise- 
<|U> ntly the whole surface of the bculy may have a greyish tinge. Oc- 
(■a.' ionally there may be one or several ccmvulsions. .\s the result of the 
ohstruction to the pulmonary ciiculation the whole of tiie .systemic 
venous svstem becomes excessively engori.'ed. Venesection may 
therefore be carried out with advantage, and often alTords <;reat relief. 
The patient should be ])ro|)ped up in a sitting position ami oxygen Ireely 
administered. This will cause an im[)rovement in the tolonr and also 
relieves the dyspn»ua. An injection of strychnine should also be given 
to stimulate the heart's acti«)n. In Very acute cases artificial rc8i)iration 
should be trietl when the breathing has stopped. 





'I iiKsK III' consiclcTi'd tiijic'tlic'i hell', silic i' iiifiisiuii is licijiiciitly 

<'ni|ili>ytMl iiftiT Kpi'iiitiniis ill till" ttciitiiii'iit III till' ".'I'liriiil iiiiiilitimi 
of tin* puticrit. iiiul skiii-^ruftiiij! iit tlio siibsci^iu'iit tivutiiifiit of u 
granulating wi>un<l. 


WinU' this mi'lliod liiui I n iiccasiiiiiiiilv niiiilr iisi' nl In sr\i'iiil 

fliffereiit \\i>iI<its for iiiniiv yi-ars <■.;/. tlii' l^ittlfs in tin- ciiolciii rpiilcinics 
at the Lomlim Hospital in IS48an(l lf<M. ami inaiiv otlifi- sporadically, 
at most of our hospitals it was Dr. William Huiitt'r who. in by 
his ,\rris and (inlo Lectures ' ajiain drew the attention of the profession 
ill this loiiiitiy- to till' ^rreat iinportaiici' of the injection of saliiii' liuiil 
in sustaining' life, if only siillicii'iit lliiid was cniploved to keep it in 
circulation. Kurtlici. it was Sir .\rliuthiiot Lane who. ap|)lyin;; the 
ahove e.\|M'riint'nts to sur<;i'iy i" two lirilliuiitly successful,-' again 
drew the attention of the piof('<m to the value of this method more 
forcibly than had been done before. 

In his three lectures. Dr. Hunter, after contrasting the advantages 
of transfiKsion and infusion, arrives at the following' important 
conclusion: ""For practical purposes all the aiKalitages to he gained 
liy transfusion may. I lielieve. be i'i|ualiy well and more readily obtained 
by infusion of a neutral saline, such as a l jier ci ,it. solutioti of common 
.salt (about I diachiii to t!ie pint)." With rega d to the direct transfusion of 
blood, he clearly shows that the nutritive value ot serum is so small 
that its chief value must depend up ; its physical jiroperties. aiul these 
are in no respect greater than of a corres|>oniiing quantity of 
normal .saline solution. With regard to the red corpu.scii's the .same 
authority writes: " The j/reatei' the (piantit\' of blood transfused, the 
longer are red corpuscles likely to remain within the circulation, and 
the more likely is their ha'iuoglobin and the iron which it contains to 
renmin within the system. Over this factor, however, we can exercise 
but little contn)l. The quantity of blood tran.sfiisible in man can rarely 
be more than about •"» jier cent, of the bl nd already in the body. .\nd 
the life duration of the led c(upiiscles under such circumstances is 

' Ilril. M.'l.-h'nni.. vnl. ii. ISSl). yy. I 17. L':i7. 

- Almut till' siiiiip time the late IJr. \\ (iiilriilgc. in i X|K'riim'iit> iin|mliii.«lic<l owiliK 
to his iinti iiii'ly death, was also proving that after hn>morrhage mifticient to Ih' fatal . ciioiitih 
ha'inoHlohin still rrmiiinci! to sustain life, if only suffic ient fluid were addeil to keep if in 
circulation. Dr. H. Sim'ih cr. whi> Mi( i r..sfully infused a patient the siilijei t of pnst-uartuni 
li.i-mnrrhaye ;is Inn-j ak''> as ISSS. sinr^ffsfs that i Vtrrh. .irr/t. Itii. j-j-t and .r.r/j-), 

and KroneclKT and .Sainier \liirl. k'ni, ll'yr//. IS7!i. No. .'►2). weri' the first to suggest 
saline infii>toii and explain its at 1i<fn. 

' Kne of the easi's is pulilished {hiiiid. vol. ii, ISitl, p. t>2U). 

34 • 


prnliiililv ti> !«' rcckiMicil l>y ii |»«'rio<l of liuuis. " Alter tlif «:rc,itfst 
liHtM nf MimhI suHicitMit ri'il corpusclt'H ulways n'liiaiii for tin" alMorptioii 
of i)xyg«"n fn»ni the liiii>{>i. providwl that the c-innilatioii w nmiiitHiiipd. 
Aftpr n 8ii(i(ipn hxts of bUMNl, the source of danger is not the want of 
ml rorpuscles. but the disturbanre of the relation between the vaM-ular 
svstt'iii and its coiitt'iits. or, in other words, the fall in the Itlood pressure 
to a point where the circnlation is iiiial)!e to he maintained. These 
((inclusions have been amply coiilirnKMl by modern e.\|icrience. so that 
direct transfusion of blcMui is now practically never eniployed. its place 
l»ein>{ taken by infusion of a saline .solution. The chief indicaf ionn are : 

( I ) Acate tnamatie uaBmia, such as occurs m the result of excmive 
hirmorrhage after opi'ratinns. or after accidents where a larpe vessel 
has been divided, such as a cut throat, or as the residt of a ru|>ture<l 
extra uterine j:estati<)ii. or post-partuni hu'inorrhaiie. The residls here 
are particularlv satisfactory. It is. of course, e.s.sential that the source 
of the ha'niorrhane should be found and the bleeding; vessel secured 
by liv'ature, or in some other way. When this is successfully accom- 
plished juilicious treatment, especially infusion, renders recovery possible, 
or even likely, however desperate the condition of the patient. 

(J) In cases of collapse, other than those produced by a sudden 
ha'morrha>;e. It has been tnentioned before (p. '-'S) that in cast's of 
colla|).se we have a low blood (iressure. the residt of iidiibition of the 
vaso-niotor centre, in many in.stances broiijrht about by the of 
fluid from the blood, a sexcrc lia'morrhaf.'e. for e.\ami)le. Dr. Beddard, 
in "Some remarks on Transfusion and Infusion" ' and in a clinical 
lecture on *' Tran»fusion," - discusses this and several other points 
in a verv helpful way and with the authority of a physiologist as well 
as a phv.sician. He thus explains this loss of fluid. "In many cases 
of collapse, however, the way in which fluid is from the va.scular 
-system is not .so obvious at first si-jht as in the of ha-morrhap'. 
For instance, in of burn or scald it is a familiar fact that the 
prognosis is detennined, not so nmch by the degree as by the area 
involved. Thus, a patient with one finger badly charred and aiu)ther 
srahled sli<;litly all over the body are both at first in a condition of 
shock. Tlie patient with the severely burned tin>;er comes out from 
the condition of shock and recovers: the .scalded patiiMit may or may 
not r(>cover temporarily from the shock, but pa.sses jjradually into a 
condition of and dies. A<»ain. a patient has a blow in the 
abdomen which ruptures his gut. he may recover from the initial shock 
and even kc^-p about for a time feeling comparatively well, then he 
passt\s into a condition of collapse. It must now be asked how have 
these patients lost fluid from their circulation and become collapsed. 

Whenever a ti.ssue is damaged, whether mechanicaliy or by inflam- 
mation, it b(X'(imes (edematous with fluid taken from the vascular 
system. Three distinct .stag(\s can be distinguished, (I) Fluid is 
rapidly poured out into the damaged tissues from the vessels. An e(|ual 
quantity, however, passes from the uninjured tissues to the blood. 
(2) During the second stage more fluid is passing to the injured tissues 
than can be got from the uninjured ones : hence there is now less than 
the normal (luantity of water in the circulating blood. For a time this 
condition does not affect tiie blood pre.sRure and pulse because it is 

1 (lint's //,).«;). /,', vul. Iv. p. 2». 
- (liiy K //(w/i. (l(niUt, July 29. 1905. 


tmporiirilv roiiipciiHiittMl fcir hy vH>M>-rcmHtric'tio» nt W«»«Ml-v«>t«wli«. 

(") In fill' lliii<l stiiv''-. till' (Iniin dI lliii<l int. i fli<' «liimiii.'i'<l tissiifs .nfill 
pofs on. till" siH't itic ;.'iiivit\' of the lilni d ri-ii's < iiiitliiiiimslw tlif vii.<<i- 
iiKitiir ctMitrt' ran no li>n).'rr kci'|) up tin- iiiti'iiiil IpIckhI iin'Nsnrf. wliii h 
fulls pronrf.«iMivi'lv till tlif licatli nl tin' |mii«'nt from failiiiv of the (crfhial 
and contnnrv cin illation. It i.s v«»ry imiM»rtant to M«>t<' that this final 
8tag»» may m't in with jrn'ut MiiKlfMiicss and fin- patient tlio More any- 
thinjr «in <l<>tit' for hini. f'oilaiisr mav develop in o.xuptly the same 
way from the ecmtimieil joss of lliiid li\ s'^vere xomitini.' and diarrlio'u. 
a« "wen in eholeia. the -.miimer iliairhuM of iidaiits. nl(eiati\ »■ eolitis. 
UHi'inia. in cases of iiiitant poisoiiiiiL'- and many other like ( (iiiditicni.-. 

Thus, in cases of collapse, from whatever when the patient 
has tthninken leatures pointini,' to hiss «)f flui<l. whatovor other treatment, 
he may retjuire. he certainly re«|uires infusion. 

(.'{) Shock. It has Imen shown (p. 2H) that shiwkis ess4>ntially <lue 
to exhaustion of the vasomotor centre as the result of excessive atTerent 
iminilses reiichini.' the centre : The Mood thus staL'nates in the lar;:e 

veins espeeiMlK those in the splailillllie alea. The lou Mood pressure 
is due. not to there lieiii;; too little fluid in the vi'ssels. hut to the hlood 
iM'injj improperly ilistrihuted. If salt solution Im- infused into a vein 
of a patient suffering from sluKk. it njay improve the 1i1<kmI pressure 
temporarily sinee it increases the intake of fluid by the heart anil c«»n- 
sei|iii.|itlv its output into the arteries. The greater part of the fluiil 
will tiiiil Its wav tliioii;:li the dilated arteries into the aiidoniinal veins 
and acciimiihite there, or it mav pass tlirou<.'h the walls of the ca]iillaries 
into the ti.ssues. On these {.'rounds we should not ,«Kpect infusion to he 
of much use in the treatment of shock. In adrenalin, however, we 
have a drug which raises the 1)Io(k1 pressure hy acting upon the peri- 
pheral arteries when given either 8ul>cutaneously or intravenously. 
.Vdrenalin is <|uickly oxidised and destroyed hy the tissues, ('rile 
therefore sum.'('sts the infusion of saliiit^ solution to which adrenalin 
liydrocliloridi' has heen added to the |)ro|iortion of I in ."»n.( M H ». When 
given intravenously the efTect of adrenaline is instantaneous. j)r. 
Heddaid recommends that it he given sulicutaneously. when a dose ol 
from 20 to minims of a I in lOlIt) solution may be safely cmjiloyed. Its 
effect up«m the blood picssure comes on within a very few minutes, 
and di.sajipears in about an liour. therefore the injecti<m has to be 
repeated hourly until the shock has piissed off. 

(Ii Rarer indications are diabetic coma and septicemia ; in the latter 
on the ground that it fa<-ilitates the reiiio\al. especially hy the kidneys, 
of the micro-organisms and their toxins. In tlie former the object is 
to the acid intoxication by the alkali as well as to dilute the 
{Miistm in the bliMHl. With this obje<-t a .solution of sodium bicarbonate 
is employed. The strength to use is 4 drachms of the salt to a pit>t of 

(.")) In the case ol certain poisons. < .(/. cailmlic ai id. I)r. ()li\er of 
Newcastle' drew attention to f he insutticielicv of washing out the stomach 
when once a poison like carliolic acid has pot into the blood, and to the 
need of infusing with siiline fluid, as this is in great part rapidly excreted 
by the kidneys and carries mtich of the poison away with it. Dr. Powell 
describes a most successful case.- 

• i'Tdfe.s.SDV .Mlhutt's .Si/.</i «( o/ Mnlii iiii, viil. ii. jit. I. |i. lUlT. 
« Lantct. 18«8. vol. ii. p. 1320. 

iNirsioN 3" 

\ H.MiMM i l. -M . ha.l. i«lH)iit tlir.-.- .|imrt.-n. ..f l> M»rv h.T 

HW,.ll.m.-.l 7 .li-«.'hin» of .mliiwry nmwwu'. m. •' •• '''i 

..f .•oniii uml .'..Ikl^-. Whil.- III.- Mtonm. I. «.,> U inir ir,l ....I , tli.- I. tt m,.. .1 

viii o,-.n.-<l <.n.l H ,. . - nf 1,1 1 r...,mx...l l n,„ |,m,.. ..t ,, - , m 

,„l..ti»n. »» frm|H.|„..llr of ItH. iIm t..l. Mm , • - pH ■ m 

m...ln.,llv i.„i....vr.l. (Ilyrrrim- in .1..,. ! o-, - ''/^ V'' ' V'' •\ ^' ' • ;., 

tt .s cl^iik t'lv- ii. l-iil ii.'vn r..iilaiii.-.l ;.llMiPiirii. K. roN. i v tt.i- 1 iin.l . ...,i|.l. l<'. 

AiM.tll.T .•oiwlitiuii wliich from itn nru't-i.t t'r.ivitv. .I.-H..rv.'* 
nuMitioii liiTi'. is gai-poisoaiog. 

Tliis ,,,,|Mv,.> I" Ik- morv .,.,„. i mi \iii. nr. Im.-I, ,m |.iu.,t. ..n.l i" 

,.„„ti.-, ili'iM uiil. u-:. Dr. T,,>l.., ' 1.- ...n. lu.M.M- fi-iii imH.y ;•«;•*; '" 

l f «li,. l ■r..|.M... ol.i H„..l. II. .oiM,!, !, 'iMl • " 

,„fu,i,,„. u-wAU .■ ~ il.l |.i..„.|.llv .■m|.l...y.'.l. U li.-- th.' |.ul-« 

„ v.i:,,,,,,,.. u' li.Mi l.v inf.iM.m il..- .■.■111..I.V. W Iff.- m an 1111- 

,,,ii-.„,ii- piiirMi 111.' |iiil>r .I.K- jiiHlifv viiii'M-'li'Mi. uifn^HMi' !.li«ml'l' ii-i- 111. II. >« ill'- !«'> ii iii. 'll' -' ai't is imi'.Ttaiii. 

(7) Kor t!i.' intravenous induction of anasthesia. iln^ 111.1I1...I 
wliii h is sfill on trial, (vitaiiilv s.-ciiis in soiix- < ;is, s ti> ..n. i in iiiy ;i.l\im 
tn.'i s A :> |«T .•.•tit. soliiti.m .if .'th.-r a|)|M'iiis t.. in..i'' >Hi-Im. t<>iv 
I hail li.'.li.iial .11 is„i.ial. wlii. ll W.T.' first .'lil|>l..y.'.l. Hi.' iu.'tli...l IS 
.•.•itaiiilv . niiv.'iii.'nt HI .ipriati-iM^ >m tin' li.^a.l. ii.'.'k. aii.l iiuHltli. wh.T.' 

til.' i.nlinaiv appaiatiH mav I.- mmk Ii In tli.^ way ..i tl ...•.■at..r. 

It is saiil tn l.^ss.'!! tli.' pi.ilialiiiit v ..I |.iilm<.n n,v .■,,iiii,l..' iti.ins in II1..S.' 
iiati.'iits siitT.-riii}: frum ..r lialiL' to l.ion.liitis. Als... wh.'ii sli.Mk i-* 
aiiticipat.Ml or is pr.-.s.'iit. tin- saline will !»• li.^ifli.ial an.l a 
siiiall .|iiantirv of aiiirsth.'tir will Im« .'mplo.vv.1. 

|,„,,,v,i,,„-.' .,i,,-tl„-i;, lii-t ,.„ipl..y.-.l l.y ».irkh«r(>' I«imhI.- who llrst 
,.,„i,|..v..l .!..■ la.ili."! ill llii- .."nitiy. -I.'s ■■ri1..'s III.' t..fhiu.,.i.'. ..|.|« ami 
iiio'l, ..f iii,la.ti..ii. H.- «iv.-s tin awoimt of I v. .' vim-* in it was 
sM.'.cs.-nillv .'iii|il.>y.'il. 

Preparation 0! the »olution. In th.- |.ivi.aiation ..f tli.^ s..lnti..n 
•mliiiarv boik'.l tap wat.'r may }»• .|nil.^ ^-al.■iv ns.^.l. In.l.'.'.l. tins is 
pr.'f.-raW.' to distill.'il wat.T. wlii. li is nsiiall\ lar from st.^ril.- ami mav 
.•onti.iii tia.vs of .l.'l.'t.'iions mat.'iials <l.-riv.-.l tlu' .-.ippi-r stills 
into wliicli it ix ir.'ni'nillv l on.lfiisf.l. , , , 

With .vLMnrto til.' Miat.'iials to la' ns.-.l. Dr. Hi'ililaril r.' .U'Xtr.w 
as cniiM.'nth snital.l.'. l..'in.!.' a normal constitn.'nt ol tli.; Iilooil, .1 
siitH.'i.'ntiv )i..n-poi.soii..ns t.. 1..- injf.'t.^.l in lar._'.' .|iiaiitit i. s. \ <> \»-r 
.■.•nt. solution of .U'Xtros.' is tlu-or.^ti.-ally isotom.^ \Mth Iminan .loo.l- 
i.lasma Tb.' mati-rial imist fr.'.pi.-iitlv oinploy.'.l is so.liuin clilorul.'. tin- 
srr.Mi.'tli of wlii. h sli..nlil I..- 1.', (lia. linis to th.- pint, or r.)i|«lily on.' t.-a- 

.1 nfnl. 'riiis has tl..^ aavantatv "f always fx'iiif: nm.hly .ihtaiiial.l.;. 

Sm h a solution is. how.'V.'r. far ir.ini l..'in,L' noii-toxi.'. an.l whil." tins 
fa.'t .l.H^s not pr.'V.Mit its us.', tli.' svmpt.Miis of p.issilil.' poisoinn-.' I)V a 
soilinm salt shoul.l 1..' r.'m.'ml..'r.'.l. ■ Th.'V aiv stimnlation ..I tin' 
m-rv.'s an.l nnis.'l.'s fr.nn slight tNviti liiiifis np t.. s.'V.'r.- < onyiilsmiis. 
pvr.'Nia up to hvp.T jivi.'.xia. rifiorH, f.'obl.' an.l rapi.l puis.-. It is 
tuitl'.'r p 'iiit.'.l ..ut that .'.'I'tain cast's ar.' much more liahlc t.) p..isonin>? 
liv soiliu Hia-i oth.'is. •• All tin' s.' casps of so.lium 
chh.ri.h' I ...oni.iL' v., 11. 1 hax.- .'. n haw h.'. n cas.'s ..I uia'nua. .luil>.'ti«- 
coma, or , hohnuia. an,! it \< .Msy to un.h'r^tan.! why. la tln-s.' t..xa.muis 

• M„l. Wront. .luiv it. I'.»'>+. ' »■"'■''•• 

» Bril. Metl. Journ., lOI I, vol. ii, p. 074. 


the patient has \mt no wita from hw vasrular aystem ; he hua uli ho 
oofiht fo havi'. and yon by trpntm«>iit make a rfuwideralile aHttitioii to 

this aiiKMiiit. Thriffdic ]ir i> cniniiiiriitivcly easily |ii>i.Hiiii«'(l. But in 
('U.s*'M (if ('(illapsc. such as iiciitoiiitis. iliari liira. ami vnniit iii<.'. &V.. tho 
patit'iit. hfsidcs water, lias lost lar;;i' i|iiaiititi('s of salts as well, and 
therefore you woiiitl liavi' to iiijift very lurj^e quantities ' .soiiiiiiii 
chloride t«) poiacm him severely." 

Better tnan a solution of common aalt is a phvuological aolutiim 
which iaiao-tonie with blooil-plasnm. The following ful^l thix ref{uirement : 
Locke's solution. Sod. Chlor. -It >:rni.. ('ale. Clilorid. -((^I f.'rin.. I'otasn. 
Chlorid. -042 jiiiii . Sod Hi< ail). •(>! >;ini.. De.xtids. I ^'im . Aijiui KKte c. 
(1*) Sod. Chloiiil. •!» ;.'iiii.. Potass. Chloras. -ii.l v'l m.. < 'ale. Chlorid. -Ol 
;.'riii.. Aij. |(«> e c. should l)e u.sed with <listllled water. The 
following forniH a ])hyHio|o)rieal .solution when adiled to tap water : Sm\. 
Chlorid. gr».. Potass. Chloridi. gni., Dextrose ii grs., A*{. Dest. 
ttd 4 ilrarhnjH. The ingredients are dts8olve<i in distilled water and 
then sterilised liy liollinj;. One tal)lespoonful added to each pint of 
boiled tap water jxives a .solution ei|uivalent t(» Loeke's solution. 

In any case the fluid should lie sterilised hy boiling and then cooled 
to a ti'ni|)erature of ll."> F. by the addition of .sterilised water, or. in 
fuses ol einergency, of ordinary cold taj) water. The greatest lare 
must be taken to see that the solution is not too i-oltl when it reaches 
the patient. 

The method of inhuing. There ure three po!<sibilities : (I) Directly 
into u vein ; (2) subcutaneously ; (:{) into the bowel. The alimentary 
(■anal is ofteii impossible for obvimis reasons. When the circulation 
has failed, absorption will be too slow and imperfect to be of 
any real value. In les-s serious cases, however, when it is employed 
more as a precaution to guard against a comparatively slight circulatory 
failure becoming more severe, it may be employed with advantage. 
Tuder these circumstances it is better to shiwly inject a pint, and then 
should the condition of the j)ulse reiuler it advisable, repeat the injection 
after ai> hour's interval, i'lie fluid should slowly flow through a soft 
nd)ber catheter pa.ssed well into the bowel. .Subcutaneous injection is 
open to somewhat similar objections: when .severe circulatory failure 
has occurred the Huid niay not be absorbed at all. On the other hand, 
in less severe cases, the solution is absorbe<l with remarkable rapidity 
and the pulse quickly improves. In urgent then, after a 
s'vere hapniorrhage for instance, when it is es.sential to get fluid into 
till' I irculation with the least possible delay, the intravenous metliod 
is indicated. In other cases infusion by the subcutaneous or ali- 
mentary routes may be preferred. The rate at which fluid should be 
allowed to flow into a vein is an important question. Dr. Beddard, 
in his paj)er juoted above, directs attention to the danger of over- 
dtstending the right side of the heart. " I have certaiidy seen cases 
where intravenous infusion has caused death in this way. It is difficult 
to say at what rate fluid can be run into a vein without this danger 
to the heart. That an apparently small ditl'erence in the blood-How 
ah)iig the veins may make a great difference to the right hea' is clearly 
shown by venesection. Here, in the course of several miiiutes, we 
abstract at most a pint of blood from the arm and produce a very real 
effect upon the condition of the right ventricle. Conversely, it «*a»v 
to understand that the injection of fluid into a vein may be 


• V ll ...... .f .l.'Ntn»M. in iKrt -uita any hut .utm- 

;;rl" .In. . ' A -(.In.... o, .,.1 "mv Im- .iv..,. 

iru ' « s'lufi ..f s.......... i.....!. ...... 

,., iJ H.. ni .n.-.....s. .....1 s.. ..fton follu*.-.! I,V ..X.rll.'i.t .vs.llts .-v . . n 

.dZluS with Whi. ll tl,.. ...11 is h.l.l.. t.. . . .ll... 'I I..- .t.l...._a ..s 4....,1.1 

of : it. " . > 8ixe. ,,,..» blunt mnnula. ami sli.i.l.-|i..i..t.'.l 'h.11..w -i.-. 1. > 
io^ r'.. nr.- ..11 that an- omM. A 1 tli.-s.- .a.i I- 
Ml 1 . l.v l...ili..- If th." su»M-ut.u..'«.us .n.-th.Ml .s t.. 1.- .■.n|.l..v.-a. 

o t ..' lax tis,s,...s ..f tl... ax.lla. A Y-.l.a,..-.l ,.....t,.M. .n..v nmnl 
, , ,.l .i...ulta..-....s i., .1.... ax.lla-. \u • 

V..SS..I .■h..H.M. is ...sually th.. „....l.a,, lmH.1..- ..r 

„,,,„s.-.l t.v a..|...- inriKMrn t.. th.. i»n..r .-r th.- m.1.- .-I m. 
tii(i'|)s t.'.i.l.xi NVl..'.'.' ^ 
tlic..' is aiiv .lilli.-.ilty 
ill tiiiiliii. a v.'i.. Ii.-r.'. 
owitifs t«> their r<»llap««'«l 
state or t«> the arraiip- 
inci.t not Mnn normal. 
;i skill tlap slio.ll.l lie 
ti.iiii'.l .i].. or j-'.-ntl." 
pri'sMiri' ...atlf .a. tin' 
liasilic or the .-I'liliali.- a 
little hinh..r up. an.l tlif 
t.unk expose.l here. Or 
tl... jnitient's may l«' 
allowi'.l to liaiij: down 
a. 1(1 llif saiilif- 
nous.ii'.'ii.'.l just ill troll' 


M< «h.Hl <if iiiw rtiiiK tin- <iiiiiiiilii f'>r ititrn- 
vi-iiiiiis inliixixii. 

sn; ^...a ^,10... ti... jr.-... ,..ti.>n t,. 

vein lH.infj rai.e.i with .liss.'ct.,.ji lo.r.-,.s. a s..,a 11 ,n. k ... .na.l. 
t with sds«..r8. care Winfi tak.M. n..t to s.-wr .t .-...n. - t.-l . I 
It wirn , 1 the ve n iii an iipwa..! .li.v.t ..... a. ..I 

rZ ,1 now lows Tl.nv,, tl..' . annula. an.l when it m full, th.; tubmp. 
3?" V u ached t . tl... i..u....l .n„A tilled with saline B..h.tu.n at a 
n;,.. .aLof iiV t.. 115 F.andpr.,>anHl inoneof the above.deHer,l.e.l 


ways, is fixccl to it. Tlu' liiniicl is in>\v liiisi'd to a licijilit i)f al>oiit 
4 ItM't. and as tin' solution Hows it is ii'placcil i»v nioic |)oun>(l from a 
juf,' held close to till' fiiiiiicl to avoid tilt' formation of huhbles. When 
suttiiieiit luis bi'eii iiifusfd thf c-uiiiiulu is rpiiiovt'tl. The vein is cut 
completely across, and the upper end tietl with the ends of the ligature 
which have been left long. 

From four to si.\ pints of the infusion fluid shoiihl be at hand. It 
.'Oioiild take at least Irom :in to ininiites to inject two to three jiints. 
the anioiint usually iei|iiiled. Occasionally li\e or si.\ pints are needed : 
the more slowly the fluid is then infused the better. Two or three 
infusions of a smaller amount are often better than the .single rapid 
injection of a large ijuantity. The chief guides are the return of the 
pulse, with increase in volume and diniiiuititin in rate (say. a fall from 
]'M)' to'.to ). return of colour and fulness to the face, in con- 
scioiisMcss. vV;c. Call' must be taken, while tlii'-Jluiil is being injected, 
that no air enters, and that there is no blocking of. or leakage from. 

the ap|)arat us employed. The 
rate of How may Ix' regulated 
by the height above the 
patient at which the funnel is 

Though the iip|iaratus de- 
sciilied above has the ad- 
vantiiges of sim])licity and 
portability, it has certain dis- 
advantages, especially for 
subcutanetms infusion. This 
is naturally a longer process, 
and unless great care is taken 
the tempeiiitllie of the ituid 
will fall \'eiy consiileiablv be- 
fore it reaches t'l" putient"s 
tissues. To overcome this 
an<l other disadvantages, 
varifuis other forms have been 

1 1 1 The vessel containing 
the fluid staitds in a water bath, the tem|)eratuie of which is indi- 
cated bv a thermometer, or. as sugizested bv .Moynihan. is heated by a 
s|)iritdanip placed beneath. The apparatus rests on a stand at the 
side of the ])atient s bed. the height of which can be adjusted. 

(2) Lane s apparatus (Figs. :{ ami 4). This consi.stsof a rubber bag 
contMining the infii.'-iiin lluid. It can be susi)eiiiled from a hook at 
anv desired height above the bed or operating table. 

(:{) The principle of the ■■ TlieriMos Husk '" has been applied to the 
c«mstruction of a receptacle for the fluiil. which is thus kept at a prac- 
tically coiistant tenijjerature for a considerable time. 

Mr. X. S. Cavniflu'i-s. writing cm tills suhjcft ' iruiiKtH on the im|)ortance of the 
tliiid liciiig hot, esiNfiiilly when eliildrcii are iiifuKed for eollnjiM' after opidemie 
HUinmer diarrhieii. He finds tluit thuugli the teiiijH'iatiire of tlie Hiiiil In tlir receiver 
is , thiit it may Ih- only "."> when if n iii lii s the mcdle in ihe niiirse of a slow 
infuxion. This may lead to an Imiii ;i>i- in ihr iiill:i|isc. '!"(> remedy this he lias 

Fli:. S. Ij>i«''s sulicutaiH'ims Infusion 

' Hiil. Mill. Jon, II.. I'.tll. Mil. il, |). Tl'.'i. 

INl rsioN 


,,„i.,„. tI. tiM' Klass t..lH.s !itt«Hn the •wk 
Innll nicc.s „f 111I.I1.T tiiliiiiK nr.- iitliicli<-<l. lUul wlini 
tl,,. l,ottlr is lillr<l aii.l I'orki'U these short tnln-s are 
, ,mnei te<t lip with the Kraclmitetl ^hisses, on.- on . a. h 
si.lf The result of having them Inrtli jsia.liiat, .1 is 
that it matters little wliieh tiiU- is attiiehi.<l to wlii. li 
Ulass. f'lr either will n-sist.T. This sim|.lih.'« the appli 
aiiee somewhat. 

"When the llask is iiiv.jtc.l ati.l th.- >ahiir nniniML'. 
air is cairi..! to the top ..f tin- Lotlle l.v mm mii-. ot \hr 
loiiu' (.'lass IiiIm.. aiwl. tli,' Ihiid i-r^\>iuil mt« Hi'- Hl.iss 

tiilK- of the op!'"-i''- ' "' 

IvKisler.ail iM^gradiiatcl to i.voni tli,- anmMiit III tlii- 
llasK <ir. as 1 |ir. r. r it. llie aniomil the |Mliellt hits 
n icivc'd. The sohilioii is eomllleted to the (Wtiellt by 
a short lenjstli of lul.her pressure tllliiiiB whieh prevents 
the U)ss of heat, since rubU-r is a |HM>r eoiiihirli.r. 

"This, hkemi»ta|>plialiee.s. is titti tl v\illi a Y pi"^''- 
so that it ean be eoniieetetl to tuo iir.-.ll, s and tli" 

iwitieiit infused in two plae,- ,,' lli.^ sain.- time. 

Onhiiarv iiifiisiim needles are ii-e,l. and sncw ( lips to 

n'Kulate the rale of How. The lolal leiij^lli ot tli.- 

rublKT tubing to each ne.-dli- slioeld not e.v eed ten 

inehes. When in use the appaiatiis is hullg on a hiKik. 

or it may Im- put on a suitulile sfaml. 

Infusion is now ptnployi'tl olteii aiitl in 

such a variety of case.s that it will be wi-ii to 

|Miiiit out that if injiitlinonsly nseil it may lie 

actiiailv harniful. In all cases a watch must 

he kept on the pulse ami on the i;eneral con- 
dition of the patient. Possible dangers are as 

follows : 

( 1 ) Sepsis. It is of course essential that t he 
tluid injecte.l shall be sterile. Care must also 
l.e taken to keej) the small wound in front of 
the dhow aseiitic. .Viiy tliick scar in front 
of the elhow-joint will eiiiliaiiass its iiiove- 
tueiit-. ami i.itectitiu iiiav lead to thromhosis Ki 
and einboli.sin. In subcutaiu'oiis iiifus on aiiy 
failure in sterilisin!^ the solution or the skin 
niuv lead to extensive cellulitis or shui^'liiiifi. 

(2) As already pointed out. tiM» rapid 

intravenous itifusion may lead to diUtetioa ol the right side of the 

heart. , , 

(.1) (Edema 0! the lungs occasionally o<-ctirs. ami mav i.e tiiecaiise 
of a fatal result. It is especially liki'ly to occur when very lar^e .,uant it les 
are injected. Anv development of dyspncra is an indication for at once 
sto|)|)iii<' the infusion. ... ■„ ^ 

{ [] If t.H. weak a solution of salt is eniployetl the tissues wdl attract 
,„uiv fluid from lla- !,!„,„l-v, ss.!s. the vcv thiiiL' that infusion ,s tneant 
to correct. A weak solution is also lik.'ly to .ause the Ineukin-? up 
of a number of the retl bkKMl corptiscles. 

4. Ijine"s!iifiisionB«!.' 
>u-piiiili-d from a stainl, 
witli Y iiiMili"M and t«" 
liiiilli'^ Ini- -iiiiiiltaniiais 
infiisiim into Ix.lli axilhe. 


Traiujushn. Din-ct triuwfiision of 1.1(,.h1 from a li.altliy individual to tlie 
patient has been r.-phufd l.V infusion of :x saline s,.l.iti<m. As. li..w. v. r. m ivccnt 
Jrears transfusioiv has . M.ploy.-d in a f.'W < as, s ,.f ,« ini. Kms anirnna, a bri.'t 
account of till' Micthod willbc given hriT. i i .u.. 

Dr. Aveling s niethmJ. nuxlilied by Mi. Ci i|.ps. is s.mpl.-. niex|.. usiv... and ha« th. 
advantage of measuring the blood sent. vi/,. '2 d.aeh.ns at each *qiieoze of the bulb. 
The apparatus Fig. .".leonsists of twoea.muhe .oniueted by a. short length of rubber 
tub,, in the eentr.. of whi.h is a rublH-r bulb, the eapaeity of which .« 2 drachms. 
The skin having been the vein.s e.\ix>.sed and im.lM's passed b<'neat i tlie n. 
the apparatu.s is tilletl with a warm i.teriliw.'d normal saline solution, and a clip 
Dlueed at either .-nd. The arms of n-ceiver and donor iM ing brought . lose togethei 
the vein of the receiver u opi-ned with sharp scissors, and pivssuiv " ing marl-- just 
below the opening in the vein, so as to prevent hloo<l obs. nnntr tli. ,uni'. the 
cannula U inserted. The otht^r cannula is then inserted into the v. in ot the giver, 
and both are held iiteadily by an assistant. Transfusion is tlu-n performed an 

*°"""Tli.- ehips having Imh^h removed from the. tube at . itli. r . iid. the otx-rator 
makes the necessary valve to prevent regurgitation by compressing with nj^-r 
am] thumb of one hand, the tulni lietween the tintral hall and the giver. He ttn ii 

Flci. ."i. Aveling"s Transfusion apparatus with two cannute and two metal sto|K(>eks. 

slowlv s,,m r/.. s tlie ball, with the elTeet of driving the water it contains gentlv into 
the vein of tli.- r.^eipient ; then, having compressed th.' tub.- U-twivn t W li .ll ,.n.l 
the reeipient, he removes the finger and thumb from olT th.' tub.' ..n th.- ..pposit.- 
side, allowing the ball to expand with the bl..o.l .■..ming into it from tin- arm ..f t u- 
giver. When the ball is full the manipulation just deserilR-d is r. iHatvd. •"'<' the 
blood liasses into the v.'in of th.' ■(•.■.•iv. r. In this n.anm r .•a. b tli.' Ijali is 
compressed. 2 drachms of blood aiv inj.'<t..l int.. tl... veins „f il,,; pati. nt. >lmui< 
the svringe arpear to b.'e..m.' I.lo. k.'.l. m woi L. iiiisalisfa. tonly. it . in Ur .l. ta. Ii- .i 
and washed out without removing till' . ..iHHil i' Iniii! tlif vi iiis 

Needless to say the o|xTation is a.roiiniaiiied by .■..nsi.l. rable ris|<. . sp, . i 
from thrombosis and embolisin. 

II. nmr-OBAfTno 

Skiu-graftinf; is eiiiploved in the treatin.'iit nf iilceratin<; or gnimi- 
latiiig .surfaces." vith a view to obtain rapid and sound lieahng with a 
miniinuni amount of contrai tion. Three methods. Thiersch's, Reverdin s, 
and Wolfe's, will be described. 

(I) Thiersch'! method is often called for where large open surfaces 
are left to lieal. cj/. after )>urns. removal of the breast on wide Imes 
for cartiiionia. uleers of th.- leg. extensive lujms. and the like. The 
followiuL' ps must be cdnsideri'd : , r 7 ti 

(a) FrciHiration of thv jmtlott and titr siirjiur I" '« '.ir<ijtcd. I he 
patient must be in a satisfactorv condition, and one wiio can be relied 
upon to keep the affected parts at rest. The surface must be either a 
rwentlv made wound, or, if an ulcer of any kind, one in which healmg has 

SKIN (;haitin(; 


bcfiuii. It is usoU'ss to firaft while active ulceration is fjoiti;; on. Above 
all. the surface must he a.sej)tic. Should the raw area he covered with foul 
ilischargiiig granulations, there is nothing better than curetting once 
or twice with the aid of eucaine if needful, followed by the of hot 
boracic fomentations and the occasional application of silver iii.rate 
or pure carbolic acid. Inanvcasethe nlcerand surrouiuliii'.'.-urface must 
be carefully prepared. The adjacent skin be shaved over a suHicient 
distance from the ulcer, and then thor()u<.'hly scrubbed and cleansed. 
Mot fomentations, which are chan<;ed four-hour'.-, are applied to the 
pre])ared area. This treatment is continued until the ulcerated surface 
is covered with healthy fjramdations. w hen it is fit for graftin!». 

(/>) PreparatioH oj the area Jrom irhuh the ijraJtH are to ta/,rii. The 
jirafts may be taken from the skin of the arm. the forearm, or the thi<;li. 
The first two have the advantafje that the skin is usually less hairy. 
Imt in extensive cases, cij. burns. <;rafts will be rei|uired from more than 
one re<;ion. The surj^'cou should always see that the area prepared is con- 
veniently situated in relation to the surface to be grafted. The day 
hefore the operation the selected area is carefully shaved and cleansed, 
aud is then coveretl by sterilisetl pads which are not removed until the 
tin»e of the operation. 

('■> ticf'Kil i/riil'limi. Till' patient haviiii: 1 n .miesthetisni. tlii' 

prepared skin and tlie idcer are exposed with ail ascpti,- pi,.<a\itinMs. 

Flo. fl. Thiersch's skin graftinit kiiifi-. 

Siiotdd the fiiiini i Ijc covered with red. healtliv. uon-exulierant j.'rauu- 
lations. the ^'ralts may be directly applied. It is better. li<iwe\er. to 
remove by j/entiy curettini; with a sliar]) s|)oon all the waterv super- 
ticial layer of granulations until the ileeper, liriner layer of newly formed 
fibrous tissue is reached. The healing edge of the ulcer should also be 
scraped away. These proceedings are followed by free oozinij; which 
nnist be stoppeil by jiressure witfi .sterili.sed swabs wrunj; (»ut fiom 
-.dine at a tem|)eratiire o! . Should T'eiiioval of the pads cause 

tii'sh ha'niorrhai;e a pieci' of steiile ijreiii piotectixf. which is non- 
adherent, may Iw used to < o\cr the surface before the pri'ssure is ap|)lied. 
(n troublesome cases a few firops of adrenalin liydrochloride (1 in llHXJ) 
may be poured on the oozin^f mtrfa^e. The prepared area of skin is 
now njoistened with sterile norrHal .sidine solution.' and the grafts are 
cut as follows : The operator, with liis hand placed under the lind). 
stretclio I he skin from sidi' to side, vshile a.ssistants. if neee.ssarw keep 
it on the sttcteh above and below With a l)road and heavv razor 
(Fig. (i) tlie {irafts are now ( ut. The iiiadi'. which is kept wet with 
sterile saline solution, is placed at such an angle to the skin that 
when it is entered and cariM along it will retnove a very thin 
shaving of the epidermis, filmy awl greyisli white, fallini; at once into 
delicate folds as it is cut .ind e.\jK)sing. and only just i xposmg. the 

' rilf liwiml >lruiii; imliM jiti. inns iiiiiy injure thf vit.ilify of the (Tiafts and heme 
should not hv uned. If any huvi- U cii ilmiI in tiit- (<r«-jwr»li<>ti ni xkixt or iriKlrunnnts » '■(•>• 
mu»t he mnoved by f«M>ly wanhing with mlinr Milution. 


torn of tl..- panillu". It is tli. n . airi.'.l with a rapid to ami fr» lateral 
, .>vM "^^^ i5..tli tl.o sk.n. svhich must bo kept carefully on 
t n. 1 t M' tinu.. an.l ti.o razor n.nst fn.m tunc to tune W 
wettJd with a few drups of sterile salt s.,lutiou. W .t 1. practue ,;n fts 
mav be cut four or five^nches lonj; a.ul .me ..r two .... h-s w„1.._ I I.e 

Z.M . ....sist ..f the h..rny and the -n-'H-'d part '''f 

lav.T th.. tops ..f the papilla, beinj.' only j.wt tre.,eh.-. ..|..m. W h 
l,e • utti,..' . i . a. h .Malt is tii.ishe.l. a., assistant slu.uld set .t tr.-e l.> 
e , ut ith a sha. p pair ..I s. iss...s. All layers ..f clot .H.zn.^ ..r 
id .""St I..' .'..efullv ..M,>..v...l in..,, tl,.. s.,r a..- t.. b.- ^'rafte.l 
wm .l;.i;ils of sterilise.1 ^au..-. 'I'l... ,.afts sl,....!.l then be ranshMn.. 

,|irectlv..n the razor, or on a h,st..lo, se. t..m-htte. la -I 
..M.l, with their cut surface in contact with tl,.' .aw a. -a. an tl,.., 
Iv . .1 ev..nlv flattene.1 .n.t with needles. Sir Wats..,. ( l.ev u 
a., I Mr. 1{...-I,a..l ,nv.. tl,.- tw..^ useful hints. • ».e f:i t.s 
i ..,.1.1 ..v..rlap tl..' e,i^'..s ..f tl..- ski... an.l als., each other, so that 
ttrt Vti raw suHa...- is l.-it .-xpo.-.l. l-r f--" -" 

spring up on the „nc..v.-.v.l pa.ts : l,,.„...v. a .)„., s.a.. v l n 
Iv'luW.p.ently break .l.-w... is 1,-lt at th.-s.- ...... s^ ^JT^^^ 

out the Kraft it will be foun.l that air . .-.•1 l-- . 'afl. 't- .'"• 

so^..n.e a,..ount of .K.zi.m ,'...'s on. an.l t!,.- l.,.l> -l-s and 
nav ,,n-v.-.,t .-.npl.-t.- a.Uu-sio.. ..f the graft. Hence, the next p.o- 

. "d ,, . is „ t ri.l ..I th.-n. l.v p.vssure. If that be attempted by n,.-aMS 

o p..,r.s U..- (grafts a.v apt' f. b- .lisi-ia..-.!. The folh.wing is the 
best pkn: strips of protective abont an iu. l, i.i br.nulth. an.l ..n-' 
enoiXt.. overlip the edge« "f th- st.-r.l.s.-. ,., ... li- . a. ... 

Umu ami subs...p.entlv nnsed in saline, aiv appl..-.l l.r.nlv m.- 
Lr fted surfa<-e. be,« at the lower part. Each s ..p ^l;'"' " 
ri„. one l.el..w. jnst as in tl..- .-ase of strapping, am they shoi.l.l e.xt.-n, 
■11 .,n t.. tl..- ski,, at .-a. l. en.l. If each strip, as it is put ...i be gras .-. 
,v tl,.- two and tir,.,iv p.-ss.-.l .low,,, tl,.- p.vssure thus applie.1 
Ufhc s both to expel the a.r bubbl.-s an.l bl.-o-l. an.l als.. t.. arrest nrtlie 
,H,zin.'*' A dr.-ss .,g of io.lofonn or cya.n.U- ^'anz-- an.l a .s..,l..-nt u..oI 
is 1, M appli.Hl with tirni even pressure. If tl..- s.nia.- l.j- .... a h-.b^ 

1,. .nnst'be kept at rest on a splint. When the ..jzin, ujs , ^ 

s.,tisfa. t...ilv b.-fo.v tl,.- s-'iafts are applied, so that risk < t then ilis 
i .^^. ,1 .... th.s a.-......;t .l.,..s not exist, the olh.wing dressing w. 

« -e excel..-iit results. Two tl.i. k...-ss..s ..f ster.lise.l gauze are cut at 
Ki a size and sl.ap.- as to cov.-r tl..- f.Malt.-.l an-n an.l .-.vtend m evry 
S t^m^iwo i!i.h.-s .... t.. tl... h.-altl,v skin. 

s .,-a.l ..ut. is placed over the grafts, and ,s s..,-,..v.l ... 1"-" ' 
, .i.itin.' its edu.>s with colhHiion. ......e ..i wl„.h sh..„l.l vwth... 

M, . 1, of tl,.- w..un.l. Wh.M. the collodion has set. a war... sa 1. , e 
, .-ntat...n is put ..... Anv from the wm.n.l can rea.l Iv 

- 1. •. i-'h t ..- ,.,.-sl,.-s ..f tl,.- L'a.iK.. a.,.l is abs.)rb..d by the h.menta- 
vh di can be changed as ..ften as is ...-.•.-ssarv .langer o 
iTtu b 1^^ the grafts. In either case th.- .l.-ss,.,,' ..„ tl,.- ,'.alt.-.l sn, ac 
sSr bo left for five or more days if Its -."•-; "';.■•< - 
ort.-. t.-.l with much care. Tf succes..f.d th.- gra I s sl...,.l.l ' ' 
colour and be adherent. If white or, ... t..,t th.-y are no alu. . 

slight, ami slow i" iiiakii«a it* appi-ttr""."''- 



Till' surface fwm vih'u-h tin? jjnifts wore tukcii may lie (Irosst'd with 
11 mil of ,stciilisctl<»auzt'. which may Im' r<Miu)Vwl after a week or tfiuhivH. 

Shoiihl it Ix' necessary, fxrafts will retain their vitality for a ron- 
siiK'iiiMe time in normal siiline at a trmiteriituiv of U»i. and may he 
(■Diivi'Vi'd ill this solution to he iiscil lor a |iatieiit at some distance from 
till' Diir fioiii whom the jxrafts were taken. 

Tlie tochimjue of graftin<; a fresh wound is in all es.sential jioiiits 
simihir to the above.' 

i2i Reverdin's method. \Vhih> uudouhtedly inh-rior to that of 
'I'liiersch. this method has still a place in .sur<;ery as. for example, in 
ioiii|)letinL' till' liealin<; of a lar^'e liurn or lujuis of the face. Owiii;; to 
its not iieeiliiii: an anu'sthetic it may lie employed for elderly patients, 
iir when an ana'stht'tic is eoiisideicd undcsiiiilile. A small portion of 
the skill, which ha.s been .sterilised, is pi( ke<l up with a needle and is 
i|iii( klv removed with Hniall. sharp, curved .scis.sors. The tiny grafts 
thus obtained are arranjied at close intervals over the };ranulatin<; 
surface. as in the case of Thiersch's prafts. ^rannlationx 
will siuiiiLr up in the intervals between, and i^radually destroy them. 

Tl |)ithelium from each "ziait may be expected to <rrow to about the 

size of a six|)eiice and then stop, so that unless they are sutficieutlv 
close complete healiuL' of the area will not be attained. 

\ u.seful and convenient way of ciittiiiv' these small ^'laftt. is to froi-/e 
the skin by meuiui of an ethyl chloritle spray, ami then to renmve small, 
thin portions of the frozen skin by a sharp razor. Freezing (Uhm not 
interfere with the vitalitv of the i.Mafts. and owing to its anspsthetic 
action, renders the operation ]iractically 

In either case a <;auze and colhidion dre88inj» may l»e employed as 
described for Thiersch's method. 

(3) WoU<>': method. Here the whole thickness of the .skin and sub- 
cutaneous . >■ is removed without any jK-dicle from the most vasctilar 
area available. While the percenta<re of failures is much jjreater than 
in Thiersch"s method, cases occasionally present themselves in which 
a trial of this method is indicated. <■.</. when a thicker coveriiii.' is rei|iiired 
lliaii is afforded li\- Tliieiscirs method, as in the palm of the haii<l. 
When this metliod is successful, its results are most satisfactory. While 
part of such a tla]) may jierish. eiioii<.di may survive lor tlu' siirijeoirs 
purpose. Mr. Keetly thus describes Wtilfe's meth<Mi.- When such a 
i;raft has been rut out. half a dozen Lane's tissue forceps should Iw 
iftaclied around its ed<;es, " Place it. raw surface upwards, on a 
sterilised towel and a convex surface, usually the thiirli or chest of the 
patient. Stretch the Haj) in every direction by piilliii}.' at the forceps. 
Shave off all the fat. Stretch the Hap ajjain to takti the fendi'iicy to 
curl up out of it. Swiufi it into place. Secure it with a few sutures. 
Rut cut away all the f(»rceps with sharp iwissors so as to leave no bruised 
skin behiiul. the most rigid asepsis being desirable to secure snceess." 
Mr. Kennedv. of (ilasgow, has published'' some figures which show 
e.M ellently what Wolfe's method may etVect in cases where it has been 
nei essary to fill up gaps left by the removal of cicatrices from the fingers 
and hand. 

' To liiki- one |iiiiti( iihii instance. Any (iiii' »ii<i has In lace (In- liirtii iiitirn |m>ii«'n»til 
In II I use i.f iiviiKiuii i,f tin- siiilp will filitl uiiefut information in a paiwr by l)r. Mellish 
{Aiiii.dJ Siirij.. I!HI4. [>. ((114). 

» Lnnffl. Mttnli 4, lW»r». » Brit. Jf erf. Journ.. April 2t», II»5. 



OwiNC, to the inipr..venient.s in ..xHl.rn surfiorv. .■specially ^^J^^l 

ro.i»natiM . . , „ ™„t,. AmpuUtions, how- 

"' "'Tiil chiS .n.o»g wUch 

are . 111 ""f"; ;>'" ■' ,,.„u\W bad cnwh™ with 

Sri fl Zfb The soft parts should form an ample coyennfi for the 

In former davs " set amputations were the rule. At tne P^fSf" ""'^ 
• 1 nl To consider the merits of each individual case according to the 

'"t'win m'w l" n^ essarv to c onsi.ler some of the causes of paiuhd 
or Ji: "ir\nsat,sfactorv st.unps. First of al thenar may ^ 

"''Claris is. of course. .Iso to be avoided, for .f the flap« 
be Jut toriong, the blood-supply is .kely to be inadequate; douglung 



iiiny f ht-n mriir niul apain lead to a painful and adhcmit riratrix. ShouW 
tlic sfvcifd ciids (if tlic lar^'f lu-rvc trunks l>c involved in tin* war. the 
latter will lie extremely tender and sensitive on even the slightest 
pressure. In other cases the ends of the larf;e nerves may l)e<onie 
swollen and bulbous, a condition sometimes known as a " traumatir 
neunima '■ ; such a swelling will also iirobably render the stump in- 
capable of bearing any pressure. Both these troubles may l>c avoided 
!)v cuttin}: the large "nerves as short as possible. Pain may also be 
caused l(v chronic osteitis usually due to sepsis. To avoid this it has 
lieen advised to cut a flap of periosteum so as to provide a riiverinji 
for the sawn surface of the bone. 

Conical Stump. In this condition, which of'en renders the .stuii.p 
{Miinful and useless, its extremity is .shrunken and |)ointed so that it 
has a conical shape, the end of the bone projecting at the ape.x o| the 
stiunp wliere the superficial tissues are tightly stretched over it. Conical 
stunip niav be the result of sloughing of the flaps, or these may have 
been i lit too .short at the operation. It not infreijuently occurs in 
< hildreii as the result of the continued <,'rowth in length of the bone 
Ironi the epiphyseal line after the operation. The treatment for this 
condition is re-amputation at a higher level, care being taken that the 
flaps are of sufficient length and that the bone is sawn through as iiigh 
as pos-sible. An otherwise excellent stump may occasional!% be fuuc- 
tioiudlv a failure owing to stiffness or want of nu)bility. This is especially 
seen in amiMitation's of the fingers through the first inter-jihalangeal 
joint, where the want of any attachment of the flexor len(h)us may 
result in a stitf projecting stump which is useless or even a source of 
annoyance to the patient. 


Thes»' will naturally depend upon the situation and nature of the 
disease ie(|iiiiiiig treatment and also upon the position of healthy tis.sues. 
The various nu-thods will be describe<l in detail in the ile.scriptions of 
amputations in the different regions. A brief summary of the chief 
methods may. however, be given here : 

(1) Th« circular method (Fig. S7). This is the simplest of -il! am- 
putations. The skin and the superficial fascia' are divided by a 
circular cut round the limb in a plane at right angles to its axis. 
With a few touches of the knife a ciitT. consisting of .skin and 
fascia, is turned up for a di.stance of about two inches in the 
of the up])er limb, and lor three or four inches, according to its size, 
in the case of the lower. The muscles are then divided by a similar 
series of circular cuts at the level of the upper limit of the ciilT. The 
soft parts are thoroughly retracted and the bone sawn through at as 
iiigh a level as possible. The circular method is especially adapted to situations where there is a siiigle bone uniformly surrounded 
bv a thicV '«ver of .soft ti.s.sues. as in the thigh and the arm. Such an 
ainputatio a be performed (juickly. and gives a good covering to 
the ex'l ot tbe bone ; the chief objection is that the scar necessarily is 
placed at the end of the stump. 

(2) Tin modifltd etrenlw awtbod. Here two small, equal flaps of 
skin and subcutaneous tissues are cut in place of the cuff described 
above. A reference to Fig. 89 will make thb modification clear. 


(.») The elliptical metbod. This respinbles the circular, but tin- kiiifo 
iust<ii<l of iMssiii;; tiiiii.Hvc is.'lv round the limb is made tn divide the 
tissufs (.l.lii|u.'lv.'" Till- iul\ iiiitiij!.'s of thf iiHMlifieatinn arc : the war can 
l)c matlc to o( ( U|>v ii position wh.T.' it will .•sciiiM- i»rcssurf ; anil 
hciiltiiy tissiK's on oni- side of n linih can he ntilisc.l wlx-n an injury 
has .■xtcntli'd more on on.- side of tin- lindi than tin- other. Tbia 
nieth«Hi can be employed for disarticulation tlirou>;h a joint. 

(4) Th« raeket ineiiieii. This is verv- connnonly employt-tl lor dis- 
articulations. .\n inci.sion is niadi' in tin- lonfjitudinal axis of the luub, 
coinnicncinfi above tin- joint .ind cxtcndintr vertically down to a sufficient 
distance l>eTo\\ it. It is then carried in an elliptical fashion round the 
liinl) back to the point from which it ori^'inally diver};ed from the 
longitudinal incision (Figs. HI. 17 and !»'.»). It will thus he .seen that 
the racket incision is a combination of a longitudinal and an oval 

(.')! Flap methods. Here flaps fashionetl from the soft parts arc 
eiiiploved to cover the sawn <'nd of the bone. They are of various 

slia])i's and sizes, and can he cut according' to the .situation of the injury 
or disease, and also in such a way as ti> .secure a satisfactory covering 

to the bone and a convenient'tion of the .scar. Flaps may 1 .pial 

or one may be larger than the other. They may be anten.-posterior, 
or lateral, or intermediate between these. 

In cuttinj; flaps care must be taken that they are not pointed. 1 hey 
should b<> bioadlv rectan<;ular with the angles rounded off. or U-shaped. 
Thev be <'.f sufficient len^'th to come tot!<'ther without ten.sion, 
but must not be too long, for then th<' blood-supply may be inade.|uate 
and sloughing is likely to occur. The tendency for the inu.scles to 
retract must also be remembered ami also that the fle.\ois retract more 
than the extensors. 

Flaps are usuallv cut so that at first only skin, superhcial and deep 
lasci.i' are taken up : 1 h.- knife then is made to enter the muscle obliiinely 
so that at the base of the flap the whole thickness of the muscle down 
to the bone is included. 

In other cases skin flaps are employed. Here the flap is composed 
of skin, superficial and deep fascia- only ; special care must be taken 
to include the latter in order to ensure a good blood-sujiply. To make 
certain of this, n few muscle fibres should be seen on the deep aspect 
of the flap. The nuiscles are then divided at a higher level by a circular 
sweep of tlie knife. 

Flaps are occa.sionaliy cut by transfixion, /.c by pas.sing a long knife 
through the thickness <)f the limb at the situation of the base of the 
proposed Hap and then cutting fnun within outwards so that the sk-n 
is di\nded after the other soft parts. This is a very rapid method, and. 
before the d;ivs of anasthesia was on this account mucli employed. 
Tlxmgh seldom made use of at the present dav. when rapidity is of 
less rniportance than thi- certaintv of a satisfact try stum]), it can 
occasionallv be made use of with advantage, for instance, when the 
flap contains numerous tendons and but little muscle as in the forearm 

(Fig. 72). . 

When flaps are ctit bv transfixion a long knife measuring one and 
a half times the diameter of the hnib is reipiired. In all other cases 
a shorter knife, not more than three or four inches in length, is all that 
is necessary. 



In aiiipiital ions fiirc must he tiiki'ii to control the lili>i-iljn;r iliiriiifr 
the o|)i'i'atioii. ( ii-iicrally this is crt't'rttMl hv some form ol toiirnii|U)-t. 
Ill soiii<> iiistaiUM's wlii-rc tin- aiiipiitatioii is closi- to tlii> junction of tlio 
liiiili 1111(1 the trunk for i-xaiiiplc. a toiiriiitjiict cannot Ih> cinploycil. 
Tlic iiicans for controlling hu'iiiorrhn^t' under tln'Hc ciniiinstanccs 
is (lcs( rilx il in the accounts of ampiitatioiiH tlu'oii){li fli<> sliouidt-r 
and lii|i joints. As a general rule in ainpiitations, drainage shouhl 
)m> secured by a tube inserted between tlii> flapH. 


Lijiatiiro of an artery in its continuity is another operation wliidi, 
owing to th»' (li'velopnuMits of siirf;ei'y. does not occupy the position of 
importance which it formerly held. As a test of manipulative skill, and for 
the knowled^ nf surgical anatomy for which it calls, it is a favourite e.\- 
aniiniition test and must on that uccoiint rec 'ive dos- attention in the 
operative surjrory class-room. It will he well therefore <o give some 
cieneral rules for the ligature of art"ries. (Jenerally speaking, though 
there are exceptions to this rule as in ligature of the posterior tiliial, 
the incision .should he made in the line of the artery. The length of the 
incision will dei)eud up<»n the depth of the vessel to Im? secured. Though 
it must not be unnecessarily long it shcnild be of sufficient length Ut 
allow of the ready identifieation of the deeper structures. This is •»f 
spe< ial importance when the artery is deeply placed, as. for instam'e. 
the lingual. Fascia- should he divided hy clean cuts with the knifi- : 
muscles should, when po.ssihie. he .separatecl. deeper planes being reached 
through the iiitermu.scular septa. If it is necessary to divide a muscle 
it should not be cut across, but its fibres should be sefmrated by a blunt 
instrument. If the artery to be ligatured is situated in the forearm or in 
the leg below the knee, it is accompanied by companion veins which 
form a more or less complicated ana.stomosis around it. .Any attempt 
to .separate the veins from ilie artery is sure to lesult in injury to and 
troublesome hu'inorrl ige from the former structuies. They shoulil 
therefore be iiu luiled in the ligature. In the larger arteries it is of the 
utmost innM)rtaiicc that the companion vein slumld not be injured. In the of these larger arteries the sheath should be opened by a short 
longitudinal incision, and the vessel cleared from this by a blunt instru- 
ment. An aneurysm needle of suitable curve and shape is then gentlv 
insinuated around the ves,sel. care being taken that the instniment is 
between the vessel and its sheath, and tliat it does not pierce the latter, 
(ienerally speaking, the needle should be passed from the si<le on which 
the companion vein is situated, in order to minimise the possibility 
of injury to this structure. The aneur\'8m needle should be passed 
unthreaded. An examination is made with the finger to ensure that 
the artery, and the artery alone, has been included. The needle is 
then threaded with a thread of the material to })e employed. Carefullv 
sterili.sed silk or catgut may be employed, the former is. perhaps, prefer- 
able for a large artery in an aseptic wound. In the of a small vessel 
when the needle has been witlnlrawn, the thread is tied tightly so as 
to divide the internal and the middle coats. In the case of large arteries 
Ballance and Edmunds (see p. 714) advise that the thread should be tied so 
as to occlude the artery without division of the coats. They advise that 
the first thread should be tied so as to arrest the circulation. One or more 
further strands aro then passed and again tied in a single knot so as 



to .K-dn.U. tlu- nrl.-i V without .Uvisioii .if its coat*. Th« two pmb of 
ZTolL tw.. threiMlH are then taken and tied ti^^her .o a» to com- 

*''*Yn H..l.j.- a., artery .an easily r.-.o.-nis.Ml l.y its ,,uk.. 

ti,„, I„ tl... iHKly llus lu-lp iM. of cour«.. ab^Mjt. In thm ra« . 
xvIm i. th.-r.. isanv (l.mht, th.' artery „uiy be rocgniswl by .■..lupn-ssin^ it 

. w tl,.- tin,;.. .n,l tl n..ury..n n.-e.ll... A'larte w thenU' J^'*. 

nis...l bv th.- wav in wIm. I. it tlattiMW .mt. hkea nbbim. w th a d»tmct 
longitwlinal gnKivc. A nerve-trunk feeb like a roundetl aolid cord. 


It 18 u.»vv nnilis.'.! that it is p. ssil.h- t.. cl-.s.- \umn<U in arteries, or 
,.v..n to unit.' tl... .' ..I . ..,,,,.1 't.-ly s.-vvr.-.l l.y nu-anH ..f mituros. 
wtth..ut ..bliter.tti.m ..I tl..- luiu.-n. an-! without ,..-r.nan.-nt ,nt.-rf.-r.-n.-. 

with th.- .ir.uhiti.m. The f.-asibility ..f sutur.- ..f art.-n.-s has 1 i.r..v.-.l bv tho .'xperiiiH'ntnl woik on annuals of a <.l 
: r ' ^:.'i alJv Carr.-! ^,.1 ( luthri.-.' a.t.l WattH.^ Tlie i^MMy oi 
:.tur.. was'tirst in.H.V l.y .M..r,.h.v an.l Sonn. It "f^-^^.^ 
th.. .' im,K)rtan... t.. kn..w lr..n. th.- . hpual i...nit . f m.'w that 
i« r„. etlure il ,H.8sibh.. An n.jnr.-.l v.-ss.-l n,a.v ... -f sn. h -"''^"'t; 'l;; 
and .(-..rtance that its ..l.lit.-rati..n n.ay ....-an th.- |.ra< tanitx 
of .v.irene, or .leath from disturbauc-e t.. the .»( ulat.-m 1 h.-n- .s 
stil Jn-at deal to be done with regard to the emp l..yn,..nt ..f art.-n..r- 
, l,a,.l.v in . linical snr^'.-ry, but it has been, or may be, of use umU-r the 
I..ll..\\iii5: cirrnnistances : , 

( I ) ..f lar;:.. v.>.ss..|h. r.,/. the can.tul. f.>m..ral. ..r ihaes. t»U8 
Dr. Lund, of B.wt.Hi/' reimrts a .-ase in which ii.' su<M .-ssf..lly 8Ut;.rett 
the f..moml arterv and the fenwral vein m a ^.rl a-t. H. both vesse s 
havin.. »>..en ,...rfomte<l by a stab fr.nn a knife. Ur Lund nmsiderH that th.- vessels und.mbte.llv saved the leg and f.iot of the patient. 
' I-., \ lartr.- arterv n.av 1..- in. ise.l f.)r the puroose <,f rcmovinR an ns and the w.inn.l snl.s..,,u.ntlv s«ture.l. jfr. Han. ley cWibes 
a„ interesting .-as- in wl.ieh 1..; att.-...,.te.l the .-'...val ..f an e„^.lus 
fr.)m the femoral art.-rv in th.- Hnt. M<,l. Joim,. v..l n. I'Or p. 7(r 

CJ) The reversal of the t-irciilation in a hnib f<.r threat-'iu-d ..r actual 
„a„.n-.,.. where this is due to interference with the LLKul-supplv 
as i';, s,-nile pinjirene. In such cases it is p..ssible that in<.re bl.....l 
conl.l r.-ac h th.- 7-xtr.-n,itv through the healthy vem than through the 
disease.1 arterv. an.l in this way extension ol the crangrene could 
be prevent...!.- That this o,.erati.,n .-an l.e carrie.l ..nt ,n has been 
prove.1 bv ("arrel and (inthrie.' It has als.. been p.-rfurn,.-.! ..n several 
Occasions on patients with ganjin-n.- with son,.- ■ It is. h..w(n . r 
„p,.n to .luestion to what extent and m what cases it shoukl bt 

einph)vi'd.* ■ r \ 

(4)" In Matas's operation for aneurysm (vide injra). 

> .loha«. Hopki.iH //<«;<• Hull., vol. xviii. .Tanuarj- 1907. 

.l,,)vr <' i'- M..ll.-r. .!»«. Sur,j.. I-JIO. v..l. li. 2.>f. : Mornston Davies, ^n». .S«rff.. wilX foinll • re^Sow ol the literatun; o£ tl« subject with an account ..f a numU r ,.f 


SI TiuK ()!" AirnimKs .-si 

I.")! Cairi l iiml (liitlni"- C'/' .>'(/'/'/! Imvi- sIidwii fxjM'iiinciitHlly that 
a |H)itii>ii nl vi'iii limy In- ^-rafti'il so as to fonii a junctiim brtwwi 
the wiil«fly Hepartttwl fitiUi of u diviiU-tl urti-ry. 

(«) For arterio-vomiu* ant'oryani, w in ciwe di ncribiHl by Dr. Oilbert 

Kfiiip.' , ... . . 

The opmtioB. In tho «utun' «f artonwi tho nvvtt nn\i\ nM'\m» m 

alisoluti'lv I'ssfiitial. TIk- vi'sscl must I xposi-d for ii (li.>«tuni-« of 

two inches ahovc and hdow the iiijiind spot. Ha'iiioiiliiijfc must Im« 
conti'illcd hy Home method whicli avoids injui v to the wall of the artei\ . 
( 'riles fhuiii»a may be employed (Kij.'. 7) or a |iieie of rtteriliwd tape 
mav be Hiipped lieneath the artery ; an a.ssistaut then places the tip 
of Kis fiimer on the arten' and by iieutly drawing on th« ends of the 
fa|M' coiitrfils the ffow of WoihI. The outer connective-tisauc nwt is 
first ^'entlv clipped away, as otherwise shreds of tills are certain to Im! 
drawn in hetwem the other coats, thus preventiiij; their e.xact a|>proxi- 

niation. Tin" rounded n lies !>■' u.sed ; lioth straifiht and 

curved should lie at hand, thouuli tin- former are, as a ^'eiieral rule, to he 
pieferred. The materiaj for the suture should he extremely line silk, 
wliich shoulil be impregnated with ateriliacd vaacliue in ortler to faeiiitate 

Full Sue 

Kill. 7. ('rili-'"f artrry < liiiiip. 

its passage throuph the vessel wall. The artery must always he handled 
with the utnuKst jjentleiiess, any rough treatpient fmm forceps being 
esiHfially undesirable. The sutures must be passed so as to bring the 
surfaces Of the itmer cmt into absolute apposition and at the same time 
to avoiil the projection of the .silk into the lumen "f the vewicl. This 
111. IV lie accomplished in one of the followiiiL; ways : 

((() Ihirminc'H mftliixl:- The follow iiii; descri|ition is taken from 
l{ur<,'hard's Sy.steni of Operative Surgery, ' vol. i, p. '2i'>'.i : 

"When suturing a longitudinal incision the thrtwl in first entrntl nlxiut nn 
eighth of an inch from one end of the incision, made to |ii ni tratc only tin- initcr 
ami miclilh> ooatH. Iiniiight out again and tied, the free ciiil lii iii}; left long. Tlie 
ii'.ille is now madi' to [n'lietrnte all the coats! of tlie vessel fioin without iiiwanis 
DM one side of the i. nt and as near the edge as possihle ; it is then carried thimigli 
the walls of the ve-sel on the o|i|Misiti' side of the ieT\t from within outwards. It 
then re-enters tho arterial wall from without inwards. |i,i.> aer<i~s tlie im i>i<>n and 
(M iietrates tho opixisite side from within outwards, thus makiim a mattress stil( li. 
The suture, however, i- not tied in the usual way. luit i- continued as shown in the 
dianrani fhronghout tl." length of the wouml : at every third loop thi' suture is 
i .irriwi liaek a stiteh'« lireadth. as shown in the dia^'iam, in oiiler to maintain the 
^(l adiiiess of the appro.\imatioii. On emerging at the other end <if the incision tho 
thread is passed through the outer two coats of the vitutel (Fig. H) and tlM-re is 
I ied in a single knot. Tlie continuous iiiattrcM RUturo thus formed is reinforced by 
a second continuous running stitch taking up the edges erf the iacision between the 
liKips of the mattress suture ; when this reaches the point at which the original 
suture commenced, the two ends are tied together and the suture is eomplete. 

"When an end-to-end suture has to he made, the liwt suture is a mattress 
suture, the ncedk^ being })>(l through uU coats of the vcifsel from without inwards 
on the proximal side, and from within outwards on the itistal side, and back in the 

> /'roe. Sou. Soc. Med. (Son;. 8oc.) 1013. vol vii, p. 83. 
' ^iM.o/^N>y., igOO,ToL xlT. 


„in.».iy .J. ni„.,i with .h.- ; . ;;, , ,,' '!' ,,,. :.' ,» ,br .wi «««' 

Fiii, 8. l»<»rrai>co'» mctli- 
(ft) /> S'l-iH^ MW 

anastomo - o; -h(>1- 

ul wture of « loi^tudinal wimnil "f an artery, 
o following technicjue for end-to-end 

•• ThrcM' ■ iwi( 

f(Trli<-<-» of t ill' Vt' 


- if 

,„-ilkarcllMnliii«lati (|>laiit |K)intsof thccircuM- 
u, thr» appli. s tm.-tiw. to two of th'T,.f 
iH tw. . !. tl..- tw..s..t....v^ into « straight liiiP.fncilltatilip 
-iitiir.'. ..11.1 pn vcntint? ii narmwiim "f tlu- limi. ti. n 
<.it..!r is w.-iglitwl l)V .1 ha-moHtat thr .•.r.;..m(. n ...■<• "I 
,„ tl..' forn> .rf a triangl.-. tho i«int« of whioh an .l.'t.|. 
on HUtun-s. and th.w will b.- no iUm-T of oat.'lm.i. tl, 
,i„g tho HUtun... Tl..- sutur,' is a .■.mtn,.....H ''V' -t-i' - 
,t* the wimrat.' «tit.-l..'« sl.o.iUl 1«- < >a«.. p.-^t tij-ht > 
,. ai.i.n>xii..ati..n. l-.t ....t t.... tightly l-st t ,..'H « 
plftml v,.rv clos.- t..s!.th.'r. Affr tl.. n,„i, .t.on ..f 
n-mov.! „f tl..- .•la,..i.s th.-i.' will ..ft. .. I«- somi- l-^""orrhag«r ;^ .t 
f.'W inUTri.i.t. <l st.t. h. s ...ay i"''.t.'.l. i cooBidcral^ BirS- . 
always stop under gi-ntle digital lomprcssKin. 

* Ann.f^ Sdiy.. 1907. vol. xlvi, p. 3.58. 

. >tr.'i ! 

titdi' t In 
rtiU 1. 

h\ ll..' tl.) 

uail whit- 
:muf(h all til 
-.■rure all." 
A- must 1 



MstM I OptraUon. or Endo-aneuryimorth»phy. Tlii-* <i|M iiU i u simc 
,t iavdvw tb.' itriiM iiwI ..f .ut. iiMl m.iuiv. may Iw .loHcri»..Ml 1p r-. It ^ 
int deMribeU by Dr. M»ti«' in I'JIKJ after an cxpfnemc of Unit v^m'a. 

Sine thiM 


iiiuiii •= 


li..rriMKt''ii imt(.-<l of t'Otl-to-t-ml anoiitijmiwfa «if 

h.i en witU'lv iitlopttHl. csj>«K'i8lIy in A.aerica. aii<l has 
III >i\ ifsuits. Ill this o{N>rati«m the sac. after the 
..iitiollt'l hy a t<>urnii|U<-t or other convwiient 
.1 frcflv No liLMtiiic- iiic apprH'il to tilt- 

ircultttioii ill the sac is imcslcil aiul li;i'iiiostasis 
ituriug the arterial oiiCu I's found in tlif iiiti'iim' of 

tlic l)ottoni of the cavity, so 
space i-i left to itc suppmation 

of the aii'-urysm is then obliteratetl l»y iiivcrtin>; or 
Mir the wall:- with the attached over- 
Tiic tlaps thus formed are 

ui> . 

it llo , 

sifomiary complications. Dr. Matas 
states that the operation is applicable to 
all aneurj-snw ia which there is a dis 
tiiK't sac "atid in which the canliac end 
f the main .irtery cun he piovisioiially 
utrolleil. ■■ It IS especially applieahle 
i, all forms of ti«'ri|>lieral aneur\.-.nis ol 
tii( !ar<.'er; n. t ial trunks (carotid, a.xillary. 
iliac Inacliid. popliteal); iMid, while the 
author has IwU no cxperieiwe with similar 
lesions of the large viseeral trunks, the 
|)riiirii>l' sii-.jested woulil apjiear to be 
a|)i)lical)i- loitic alxlomii il and other 
accessible I" as of abdominal aneiir\ sm- 
Tli" operation is based upon the foll(>\. ki«; 
mtj principles; (I) The sue is refjanU-l a- 
a larjte diverticuluni or prolongation o/ 
fhe tmrent arterv: (2) the lining nvetnbraiu of the sac is a coutii». 
r .f r!;;- iutiilta v- hich HiM's t\w interior of tb« artery; (:J) that t^ 
t^ac its. , when not ilisturbed from its vascular connections, is capal 
» Ahh. Surg., 19»3. voi xMvii, p. 

|o. Knil'i am iin 
rhai>t>y. (.Matwi.) 


c.f exhibiting all tlu- reparative aiul ^•^^elu•Iati.l^' reactions which 
characterise the enilothelial surfaces in tieneral , , . , , 
The <.,.erati..n is .leseril.e.l i.y Dr. Matas under the f..ll..wn,f.' . 

|„„„iaj,'. I'v n,>npn.ssi„„ l,y CnleV . (Fi. 7). by a traction loop (*e* p. 51). 
i.r liv <lir,-. t iircs^un- from 'III- liiiiji '' "f i'" . . 1.1 

hu iMon of tV! skin exposur- of the 8ac. Thte must be thoroughly ox- 

' in? of the KK- nn.1 evacuatio,. of it«content., recog,... >on of l''" yi- -^j 
nuinl.. r of oiK'niiics. &c. A free incWon in now made oiwuiig the sac from on.- 1 ml 
o : er The ^ntaincd blood and . lots an- evacuated au.l the niter.or o the 
c ,vi V Splayed by free retraction of its e.lges. In a fi.sifonn aneurys.n two h.rge 
Uu, s^n «.parat«l by a -riah.e^t.un^h o^^ 

lloor of the parent artery. A «ae- 
cular ancurvsm -liows a single ojKm- 
inH which I'omi' ts the sac with the 
main artcrv. S^ areh must abto be 
made for the oiKiiingH of branchwi 
springing from the wie, which if not 
»uture<l would give rise to trouble- 
some hannorrhage. If there is any 
lilii'ding from the oritires as a result 
of the free collateral supply, the 
closure of these oiM-nings by suture 
should he at once proceeded with. 
Laminated clot is then cleared away 
hv (iently scriilihi'ijr the interior with 
sterile ga\r/.csr)ake(l in saline solution. 

(4) Closure of the oritiees in the 
fusiform tvi.e of sac (Fig. Hi). The 
nyslcmatic closuie of nil visible oriti*-!* 
Kio 11. Endo-»ncur>'8roorri»phy. (Matas.) nhoukl now be proceeded with. 

Either silk or chromicised cat-gut 
may be eii.nlovcd. Full curved intestinal needle, are best. In the larger oiM iiings 
tkM,efMlle ihould iK-netrate at least one-sixth or a quarter of an mch beyond l e 
margin of the oriKce, and then, after reappearing at th.; margm. dip aga n nito t e 
H<K,r of the artery, and continue to the opjiosite n.argm a.s 111 " ' 

the oiH>nin«8 mu^t be closed quickly the dip of the nee.lle nito the floor of the 
t^rmS?^bo omitted, and tl.e Jarpm brought quickly together a con- 
tinuous suture. In all cases intima must h.- l.rought m o exact contait 
intima. A second row of sutun-s to bury the first is oft. 11 advantag. .)tis. 

^) The snecular nneur>sn. with a single orili.v. suture w .th th e 
view of pn'servhig th.- lu.ucn of th.- pan-nt nrt.-ry (F.g. 12). The n.trasair.da. 
future of th.. ..rili..- ..ot ....Iv in-rmits of th.- radical cure of the aneurysm by e 
ts orifice but also all..w> ih.' rest...ation of th.- affected artery o itn iunct.o«ml 
and onaton.icnl integritv. Tl,.- sa.ue ..cedles au.l mat.-nnis should Ix; u«-d as m 
the nrcvious cus,-. The sutur.-s sh..ul.l Ik- ins.-rte(l at a sufficient distwice from tht< 
us.iallv thick H..d sn..joth margins <,f th.- opening in order to secure a hrm "nd dc-ep 
"„1,| ,,f the lihrous basal nu-.„brane. The needle should Ik, made to appear just 
«ithi.. the lower e<lge of the margin, care being taken that when the ««•«'•';; "'•'■ 
lightened the calibre of the arter>- will not be cncroa. he.l 'M>"" 
its lumen, and that the thread* »ill not be brought ... contact the I.I.kkI th 
lumon of the vessel. Greater care h.- .-xcrcised in sccurn.g a< .•.> aptati..ii 
inthtachissof casesthaninthefiisif. rm typ.-. . .;,;,.„ 1,.,.,. 

(6) Removal of constrictor an.l t.-st of sutures. \\ hen all visihU- orifices have 
been cUised the provisional cxpc-licnt f.)r tlu- . irculatu.n is r. uH.v.-.l. 
The interior of flu- cavity shoultf now U- i^-rfectly dry. If there la- any """"8 
capillary points th.-se will usually be stopped by jfremae and by the moatui adopted 
to obliterat.- the cavity. • . , 1 j a 

(7) Obliteration of th.- sac. This is eflect. d I.y tuniiiig the relaxed flaps of skin 
into the int.-rior of tlu- cavitv. If th.- sa.- has u..t been pn-viowly dissi-ctcd from its 
summndings. th.- skin flaps will Ik- lin..l on their inner surfaces by the smooth 
Hiic walls thus eoiwtituting an aneurysmo-culuneouH Hap on i-ach sKte. Jnese 


II ...s .an tlu n Ik- .lowii i.i the liotlom of t1.r CftV.ty l.y two n i.... sut.uvs 

. wl.icl. should vm-trote tho entire tlm kness .,f ll,.. sm pr,,s,,mu a rnnM.l. rah e 
«rt on of the HB^ wall. In this way a loo,, is forn,-.l. (he nvo .m.Is of win. I, a.e 
ra^ri^ through the skin flaps l.y transHxioii a stra.^l.t H- vrnln, s m.m;.I L. 
anT then tied firmly over a ,.a.l of >.'au/..- aft. r tl... flaps hav.- . aivlnllv 
rUmon The edgrs of th.- .km which thci. . oni,. Int., .onla. l ,n th. a.l.iustr,l 
"i^rL unit...l by a f.w sut.-vs. Wlurj. .h. lM.I.,n« t.nnoMr 

r uslv exisled ih.-.v will h.. a vary,..,' -., -I.p h a.-,.,.;.l.nR to t 
ii/!,. of flu- sar ; ..o n.vity is l.ft a.ul tl.,.v .s ..o ...t.I for < Th« 
coilat.Tal l irtiilatio.i. which is iis.ially i.i.portaiit in 
the vicinity of an aneurysm, is also respected, and in 
lliis way tiic iH-st eondit"ioTi for the niaintcnanee of it 
lii allhv nutrition in the sac and in tho parts l«yoi,d 
the aneurysm are assured. Dr. Matan suggests that 
in iliac and other abdominal aneurysms tho (H ri- 
toneum covering tho sac should be utilised ni the 
same way as the skin in external aneurysms in the 
process 6( obliterating the sac. 

Remits nf the Operation. A nunilier of .-ueees>fii[ 
cases have been recorded in the various niedaal 
journals. Ur. Matas. in a paper read Im Ioiv the 

Vmerican Medical Association in I'.Mi*^.' collected a 
total of Hfl cases. Of these 7 <li<d after the opera- 
tion, though in ."> of these the o|K'ration was only very 
inilirectlv the cause of death. Of the njnaining "S 
eases there wcro only 2 cases of seeomlary ha>mor- 
rhage. 4 of gangrene" and only 4 relapses, all in ru- 
eonstructivo ojKTations. 


The operation of lyiiiphaiiiiioplrtsty 
be described here. This was originally intro- 
duced hv Mr. Sampson Handlcv in IIKW* for 
the relief of the condition known as " brawny ami," which not infrequently 
appears in the late stapes of carcintima of the breast and is the scmrce 
(,f <;reat sufFeriiif; to the patients. Mr. Ifaiidh'y points out that the 
lynrpliatic obstruction is due to the pernieative spread of growth cells 
ah)ti" the Ivniphatics and a peri-lymphatic fibrosis which is tints 
pi(duced. ''The plug of cancer cells within the lymphatic, continuing 
to proliferate, finally splits up the lyniphittic. Around the micro- 
scopic trauma thus caused a vigorous round-celled intiltration occurs, 
to i)e rei»laced later by a capsule of newly forviied tibn)Ms tissue, 
which contracts upon, and ultimately .strangles, the enclosed cyliixler 
of cancer cells. The original lymphatic ves.sel is replaced by a .solid, 
microscopic, fibrous cord, and the process of peii-lymiihaf ie fibtosis is 
ctmplete." The method which Mr. Handley emi>loys consists in intro- 
ducing into the subcutaneous tissues of the .ilTected limb a number of 
buried silk threads, running upwartls from the wrist an«l terminating 
above in the healthy tissues in or beyond the axilla. " The operation 
is closely aiudogous to the drainage of a marshy field by lines of buried 
pipes." The operation is a simple one. An inci.sion is made near the 
wrist. Through thk a l«mg probe provided with an eye is thrust upwards 

Flo. 12. Kndo-aneiirj'smor- 
rhaphy. (Matas.) 

■ JoHfii. Amer. Med. .lm<>e., vol. li, p. 16«7. Dr. Mataii has also pulillshrd a later ami 
more complete list of cases (Tmim. Amer. Hurg. .^•w*•.. 1010, vol. xxviii. p. 4). A dis- 
eiissioi, on the Suriricarreratinent of Aneurysm, oiienwl by Mr. (iillicrt Harling U fuw tho 
SuiKical .Sei tion, Itoy. Sik;. Med. (Tran». Roy. Sot. Jfnf.,8urg. Sect., Jum>. 1IU2. p. 13t»> 
may also bo read with advantage. 

> HunteriMi Leotaief, Lawtiet, 1908, vcO. i, p. 1207. 


rnfwl^ 'nSt^^ UP-^^^^ directLn an.l tho silk a,ain .Innvn 

5L"^nrthe a Jncc of organisation and ...adulation tho .ntenor 
ensure the retention of ite capllan' power. Han.Uev in the 

Tho following is one of the caaes described by Mr. Handl.N ni 
paper quoted above : 

The patient, a w..n..n a.- ^' -^" i--- rl'^iV:^::;^/^^ 12 
MUI,ll. «. x Hospital «>-> •'^'""•"'•> • ,„ .", ,;,; ,. „L In 1«9« recum-nceH in ' 

th.- Lreast a.i.l ax.lla w- re n n.uN.d ,^Vmm the axX In Hm tla- .i)rl.t am. 

Unfortuimfly nu.iHur.'ni..nt-, of ll... > • " ' ' ^ ,^ , i„,„i,k.nfi- in Hie .-ai-n.-st 
HO that no ,u...,ir.t.. r-. o.,! : " ^l '^^ ( ami F.-l.niary 24 tlu- 

,lay«. aft-r thr ..p.rati.m. '■ .' •„,, ,„,i„w thr .-Hk.w from 

loj t„<,li ; a.ul H. ,n. h.s I.. I0W '' 'V'" „7|V Th. movi-iu entH of the liaii.l 


Mr. llandlev also suppests that this operation v.ll be found of use 
in other cases of lymphatic obstruction, such as elephantutsis. 

» Proe. Boy. Sue. Mid. Vliii. .Sif., IVbniary I'JO'J. 

flf/IPTER fV 


Praetieal ii— <niiiiril jmn^- 1- P<t*tt*4ms ftf nfcc jointi* 0iji. l->i i'W 
has to be rm¥'mlM'r«4 : (a) w frimr : ^^\l^ikmA. 

((() In fmta. Timf «et» ef c. o r »Mynnd hen*, t him p fc iMt 

i xiu tly to tho joint* <'>f th*»**. the |f»w»»st f^niw is jiBrf wIhw-* tJt** 

jiiiiit. tilt' iniddli' IS ii|ipi)sit.' \i till' intiM |i|i,u,iiiifi';il jtiiiit tin' li»»iJit»nt 
lii'itrlv tlili'i'-i|iiai'tt'is (if iiii i " h u-Uiv tin' niftii' ariiii-|ilinliiii'_'(',il jiHtit. 

(6) Itchind. It is to lif i--iiii- ^lici'-d <|i that in indi caHf ii i> fin- 
up|M?r bttiic vhifh forms tlif prm«Btiu«nM-«'. viz. tW kttueklo is loriwwl 
by the head i>f tht' iut tii(ar]Mri 
Ixmi". tiic iiiter-phiUaugeal pro- ^ 
miiu'iice t)y the head of the first ' 
jilialaiix. ami the tlistal one by ^.^^Kt C 

the distal and the inter-plmiaiifieal 
the joint is concave from side to sitle. and pn'scnts a concaN it \ towards 
the tips ; in the metBcarpo-pliahingeul joints, on the other huuil, the 
convexity is towards the tiiitier-ti])s. 

III. 7'//c Tliiiii. This fibrous tunnel, which extends downwards to the 
bases of tilt' tlistal plialaiifjes ami upwartLs to tlie palm, is lined by a 
s\ noviul sheatii ami transmits the lle.xor temloiis. The slicatli of the 
little finger is directly continuous with the palmar bursa which encloses 
the tendons of the flexor subliinis uuil the flexor profuiuliis diiiitoruni ami 
extends upwards into the forearm. The sheath of the tliuuib also 
extends into the foreartn and tisually commtniicatea with the palmar 
liiiisa. The tlieca i;apes widely when cut. and hence then' is. especially 
ill the case of tiie thumb ami the little fiiifjer. a channel aloii;; which 
infection can easily travel to the pahn ami even to the forearm. Cari! 
should thus be taken to keep even such a small amputation as that 
of a finRer perfectly aseptic. The flaps of an amputation through 
ihimaged parts shouhl not be too cloeeiy sutured ; tension should be 
avoided and drainage provided. 

> Th« teroM " above " and " below " moan nearer tu and farther fium the trunk. 

Suifiicr Mwikiii|.;> nf llii- jiiiiil^ I'l 
the tili^TH. 

11. Sliiiiie of (lie jiiiiils. Ip 




Vs the rule is alwavs to rcinovo asiittl.' as possible, tlie aitual iiietluHl 
a.ioi.ted will alwavs llepeiid upon the aspcrt of the iiiifjcr from which 
uiidaiiia.'.-d soft iSaits can l.c ohtaiued. The following amputations 
should therefore he practis.-d. of which the first two arc the best : 

(I) Loiij.' palmar lla]) (Fii.'s. M. Hi and liO). 

(■>) Lonn palmar anil short dorsal Hap (Fijjs. i« and 20) 

(.'{) Two lateral flaps (Figs. 17 and Thcee may be («) equal; 
(6) unequal. 

(4) One louir lateral liap. 

(5) Two eipial aiitero-|Kistprior flaps.' » fru u 
Of these the palmar Hap is us\iallv the one made use of. Though. 

as the hands are hv far most fiv,,ueiitlv held in the prone position, a 
dorsal Hap falls more ea.silv into place, and <nves a more concealed scar 
a palmar flfi has the jireater a.' vanta.v'es .if a scar wIik Ii is not press.'d 
Utwn when anything is held in the hand, of pos.sessinji finer sensitiveness 
*^ in touch, and better nutrition ; 

furthermore, this flap is available 
even in the last phalanx, where, 
from the presence of the nail, a 
dor.sal Hap is not obtainable 
(Fig. H). 

Amputation of a Distal Phalanx 
by • Palmar Flap (Fig. I I). 
^ First Method. The hand, to- 
gether with the sound fingers, 
should be completely covered by 
a st.'rilised bandage. The hand 
then being well pninated and 
the adjacent fingers well He.xed. 
the sur-'onn. having placed his left fon>tiiiger just below and behind 
the joint and Hexed the phalanx stronglv with his thumb (a step 
not alwavs eas\ with infiltrated tissues), cuts* with a slightly seim-lunar 
sw.ri. and drawing the blade from heel to toe. straight into the joint. 
To effect this m-atlv. the convexity of the sweep should one- 
twelfth of an inch below the prominence or angle produced by flexion, 
the sweep being made by laying on the whole edge of the knife, while 
with the p»)int. as this incision begins and ends, the lateral ligaments 
are paitiv cut. The joint being thus freelv opened, the knife is in- 
sinuated in front of the base of the phalanx (a step which is facilitatetl 
hvdepres.sin.' and pulling on the plKilanx). and then, being kept ch)se 
to and parallel with the bone. cuts, with a »t<M-!y sawing movement, a 
flap well rounded at its extremity about two-thirds m length of the 

pulp of the finger.^" , , , n , ^ i 

Second Method. The hand being 8upinat«d, the finger to be operateii 
on extended, and the others flexed out of the way, a palmar flap is cut 

« These win pri>du(»»rtump with an oxiin«e«l war. u i i -l,. » 

» The knife in »U thono finger amiHitations shoulU Iw narrow, short, and sicmhtr, yet 

" "i f ilir llaii i- iii-iilli. i. iit. the lii .iil i.f llic -c^ uikI plialanx must Ix) removed. In this 
a.ul in ..tli. r atm,utatiuii> iii the li»n.l. owiny to tlie soft l«rt» cut throu.!<h iKMns; often 
inliltralwl nn<l lixr<l. the flaiw aro easily maUe too short, from the dniro of tho surgeon 
to leuvu iw nuicli as possible. 

Kk;. U. 


by transfixion, the knife being entered just bekw the pahuar ereaso. 
till- joint being then opened from the dorsum as liefore. and the phuhinx 
lastiv disarticulated. To cut flaps by transH.xion. however, is not 
satisfactory in aiiiputaf ions of the tinnier. iir F. Tii'vcs sums n\> tliis 
(juestioii ill the followinu' words: "" In no o|)t'rati(m iijioii tlie tiiifjers is it 
well to cut the fia]»s hy t lansfixioii. In cutlinjia jialinar flap by this means 
tbefe is danger of slitting up the digital arteries. The Hap, moreover, is 
apt to be pointed and scanty, and to contain fragments of tendon." 

Third Method. If the surgeon has no narrow knife by him. he may 
modify the last method by cutting his palmar flap first, but from witlioiit 
inwanls; lie then opens tin' joint from the dorsuin. and disarticulates. 
.\s a rule no vessels recpiire ligature. Any tendon that i.s jagge<l should 
be cut -sc|uare. 

J)l/firiiltii'.s iind iiii.stokcs in ampukttion nf it Dislnl PhaUntx. (I) The 
flap may, of course, be made too short ; it is^often made too {K>inte«l. 
I would take this opportunity of pftinting out that m the bones of tlie 
hand are large in relation to their 
soft jiaits. the flap or flaps sliould 
alwass be cut sufficiently long. It 
is. indeed, a golden rule in all 
amputations that tiie flaps should be 
of sufficient length to fall together 
easily over the end of the bone and 
to come together without the 
slightest tension. If the flaps fit at 
all tightly it will be found when cica- 
lii-<,ition has occurred, that the scar is 
uilherciit. painful, or prone to ulcerate, 
or the bone may tend to make its way 
through the skin when pressure is 
made tip in the stump. The student 
iiuist then in this, his first amputation, fix u|)on his mind a rale «4iieh 
must be followed in all amputations, large or small - to measure with 
the eye whether the flap or flaps will be sufficiort, just before each is 
(inally cut. 

el) If the phalanx be not sufficiently fle.xed. or if the site of the 
joint has not first been marked out with the nail, the latter will not be 
readily opened. It is very common for .students, forgetting that in 
the case of Ciuli joint this lies below the correspoiKling iironiini'iic'' 
( Fig. 1:5), to cut above the level of the joint here, their knife sawing against 
the neck or head of the second phalanx. 

(.'$) It is often difficult to pass the knife readily round the bast! of the 
phalanx, especially in cases where the blade is too broad, or where, as in 
well -developed hands, the of the jihalaiix is strongly tubeiciilated. 

(.4) If there be any hitch in ))assiiig the knife behind the phalanx, the 
outline of the Hap is very likely to be jagged, and sloughing may then eiisui-. 

Amputation through, or disarticulation of, the Second Phalanx ( Kig-i. I (i, 
17. IS). 'J'his. as a rule, should be performed through the phalanx, and, 
whenever this is possible, at or beyond its centre, so as to leave the upper 
half or third of the phalanx, and thus ensure the prc8er\-ation of some nt- 
tachmoiit of the Hexor .■.iiblimis. While ihe rule iiol to amputale a 
linger at the joint between the Hrst and second phalanges, and a fortinri 
through the fint phabmx, a a aouud one, as there is a risk of leaving 

Vic. 1.">. a. Flaps aftrr iiiiipiil;il inii 
of ti'i'ininal |ilialiiii\. ii. Flaps all< r 
aiii|iiitatiiin t hniuKh Heconii plutlaitx. 
I-. AiMpot'ition of iwonil phiilttttx 
( llf-at li). Inrarh casr a ! it t'nt-|M inferior 
Haps have Ihtii inailr. In it thr llr\iii 
triidon. and ill < Imtli lli xoi anil cv 
tciLsnr ti'iiilciiis, shiiiilil l»' siilurril a> 
ilim-ti-il aliove. liaviiiK Ihtii lirxl rut 


Vn. Ifl Amputations of tl... ttngt-r. and the thumb. Jh. surface marki.m of th.. 
" ' MiiH rHiialjialmar arch in also nhown. 

together the ttexor and extensor tendons (cut long square) over the 
end of the bone (Waring). 

(,) In the ca«.. of the index .in.e.. .he ^S^I^.h^tK^he 
,„ the thumb, an in holding a inn. (-2) ' ,f,/J^X.^K Kxi-d, and it 

p„,ximal Phalanx will give grea er >;>•■';;;;;• >^ J, ' , - Z^m^^ the pK,ximal 
may on this account «■ U ft ]. V j'''^"' (4) Where 

..Imlanx of one should, if , V i. ilr uSt^ter the r»k ot itiOuL^ haa 
' ..,.n. insist on ... iuy he , 

t^■•■,'l;:^'^:ror to th;. extril the „,ore the aw hcU, and the younger the 
u greater will .. the --ment gajn^. ^ ^. ^^^^ 

IhrouKh t..e tendon. «d their «heat..s m an m v , . a. h^^ ^ct^^^_^^_ 
r;2n\tTSat.;;i SSU^y madra'^Vtt^krnt there for those tendon." 



■ethodi. (I) ' ig palmar ordorsal flap (FigB. 17 and l."*^ or hv 
(lorso-palnmr flaps, ti c flaps being equal, or the palmar one the longer 

^^^%)'bij Ihrso-fHtlmiir FUips. The surgi'oii. haviii},' iimrkwl with his 
left forefinger ami thiunl) the spot whoro lie iiitciuls to divitlf thf Ixmc. 
cuts between tliose points a short, well-roiuulcil dorsal tlai) of skin ; 
he then sends his knife across l)t"lo\v the bone, making it enter anil 

Vn:. 17. Ani|)utfttion of the linge rs nml tho thumb. 

cmorfio at the base of tlu> first Hap. aii i cuts a palmar flap about two- 
thirds of an inch in length. ai\d not pointed. The flaps arc then re- 
tracted, the bone cleared with a circular sweep of the knife, and divided 
in the manner given below. 

While long palmar and short dorsal flaps will give the beat result, 
equal flaps, or a long dorsal flap, may be employed if there is more 
extensive damage to the soft imrts on the anterior aspect of th<' linger. 

(2) By lAttvml FlaiisiVigs. l(i and I"). The site wiiere tiie l)one is to 
be sawn having been marked by the left forefinger and thumb placed 
on the dorsal and palmar aspects of the finger at this level, the surgeon, 
looking over the finger, enters his knife in the centre of the palmar 
aspect, and carries it. cutting an oval flap, about two-thirds of an inch 
in length, to a corresponding point on the centre of the dtnaum, and 
then from this point down agMn over the side of the finger neatert to 

him, to tUc point whoro tin- knife was tirst insert. d. Tho Haps beiiifj 
dim^ up M thick us iKKSsihle, unci tli.- ivinaimng soft parts severed 
with a circular sweep, the bone is divided with the «iw or boue-f..n eps. 
If the situation of the damaged tissues renders jt desirable, one flap can 
be cut longer than th.' other. In using the bone-fort-eps the concave sur- 
face is alwavs to be turned awa v from the trunk ; if this precaution is taken, 
and the Iwnes severe.l .luicklv with a sharp instrument, the section will be 
clean and not crushed. it'a tine saw is much the U'tter instniment. 

Anratetioa of a Finger, » .7. «econd or third at the Metacarpo- 
DhalasCMd Joint (Figs. 17. 1«uud20). This, the amputation 
in the hand, being re.iuire«l for severe crushes, tuberculous ( am 
»„me cases of whitk>w, should be often practised. Before it is employed 

Vi, IS In thr M . .111.1 tinjj. r „ini..itfttion through the Hooon.l phalanx w Hhi.wn. 
I .■■■!„,,,;. Ik "« . ivi.L d iK luw th.- in<. rtion of tho flexor w.l.Iim.s. In the .n.lrx 

PS is liJuir.!. Thr Haps for ami.utation of th- mdfx in«. r .t. »!..• i.u ta, a ...^ 
h^W^^^^^^^^^ ,«,rt..f> » mw p a,. .! , ,th. r 

to tKd a Iv . .h.. h<-a.l of tl... nu tmarpal l.uu.-. In th.' thu.i. . tl,.- Ila,,, f..r 
ImimtaUonaJtl,. . ,p.^ 

may he wounded r. ''is amputation. L.pitur.- -f tlw ra. lal . rt. ry •» tho tack ot 
: wrist is also n pri scuttd. p. 1-4.) 

for an iniurv, the remarks on the conservative surgerv of the hancl 
(see p. 71) shbuld be consulted. It is usually performed by the moditie.l 
oval method, the en raqneUe of Mnhfwjm. Lateral flaps iiiay also be 
emi>loyed. Other methods, to be used according to the extent of damage 
to the' soft parts, are described below (Fig. 2U). 

The hand having been pronated. the radial and ulnar arteries con- 
trolled by a tourniquet, an Esmarch's bandage, or the fingers of an 
assistant "above the wrist, some sterili.sed gauze wrapped round the 
damaged finger, and the adjacent ones fle.xed out of the way or ..ek 
aside with strips of sterilised gauze, the point of the knife is inserte.i 
three-quarters of an inch above th« head of the metacarpal bone, sunk 
down to the bone itself, and then carried down m the middle line till 
it cets well on to the base of the phalanx ; then diverging to one side, 
the knife is carried obliquely well below the web ' across the palmar 

, w.-l, will. U.a.l t-. n.-.r.- ha-roorrhaKO and it may be diHUidt to 

s,., ur . he v; The in. ision >l..a.l,l pass al.out half an inch betew the web o herw..* 
The . wi be d IKcultv in brinKini! tlu' llaiH totiethor unloj» the h<»d of the niotacar^ 
Is r"nove.l k' en tLi tli«e U likely to be tenrion on tho .utttlM. «kI thu. bIow aad 
painful healing. 



iisp'Tt (if i\u' lirst phalanx Ik'Iow tin' paliii ami lln-ii arnuiiil tlif otluT 
ttide of the pliaiunx (aliH> Im'Iuw the wi'b) hu uh tu joiit tlu' 8trui)|ht juirt 
of the incisum which lies over the heud of the iiu'tuearpul bone. 

iMtertil Flujui (Fig. 20). In practice, enpefially in the country, where 
an ana'.sthctic is not always easily available, it is much jm'ferahle, 
liccau-sc i|uicker, to make twu sciiaratc iiicisiuiiH. each i)('i»imiiiij; tliiee- 
(juai'ters of an inch above tlic head of tlic nit'tacar|ial bone, and nici tiiifi 
ajfuin on the centre of the base of the palmar aspect t)f the liist phalanx, 
well below the pulin. insteuil of carryiiif; the knife continuously round 
the tinker. This method is not only quicker.' but if does not leave, 
as in the first inethtKl. a suiail tongue of tissue on the {wlnutr aspect, 
which is a little difficult to adjust satisfactorily, and behind which 
dis<'liai}ies may colli i t. 

Sir W. Watson Clicviie and Mi. Miiii.'li,ird - point nut that where any 
such j)rojectioii i.s jiresent, as in a wmKiii!.' maiTs hand with a \ery 
thick palmar skin, the removal of a V-slia|H'd portion here, after the 
coin[>letion of the amputation, will cause the entire disappearance of 
the nrojcction. 

whether the method by lateral flaps or #•>/ rot/iittfr be employed, 
till- knife should be used bolillv. the e.\ten.siir tendon seveied in the 
lirst incision over thi^ head of the metacarpal bone, and the soft parts 
at the sides cut to the bone. Then, the fini;er 
being now extended, one lip of tin; cut tissue 
is taken up with the finger and thumb, the 
flaps arc dissected up as thick as possible, 
tendons cut clean and square, the lateral and 
;iiitetinr lii.'aments severed with the point of 
the knife, and the joint opened by recolK-ction 
of its site well below the projecting knuckle 
{s(v J). 07. Fig. 1:}). 

Di.sarticulation will be facilitated by 
ing the finger, first to one side, aiul then to 
the other, so as to render tight the parts which 
remain to be cut. On no account sin. lie 
knife nee(lle.s.sly enter the ])alm. This wih oidy 
lead to troublesome bleeding, especially in in 
flamed parts, and perhaps to the spreading of 
infective inflammation. A caution may be 
given here which applies to all amputations, 
but especially to those performed for accidents, 
where it nuiy not have been ixi.ssible to secure 
ab.solutc sterilisation of the parts concerned. 
It is very easy for the tendons, where they 
are drawn down in order that they may be 
cut short and square, to carrj' up infection 
as they retract into their sheaths. .Vt this 
stage especially it is important thoroughly to 
irrigate either with sterilised .saline .solution or with some weak anti- 
septic lotion, such as carbolic 1 in 40. 

Where strength has to be considered rather than appearance, the 

' H<H iiuH4' it »vi)i<l» the hitch UKunlly met with in carrying the knife around the hone 
of line iingcr between two others. 

» Mannal 0/ Swgiral Treatment, vol. ii. 1». '>12. 

Vii:. Itl. Ain|iiitatiiiniif tlic 
Miiililli' lin;.'ri' l>y lateral tla|>.x 
( III alio. 'I'lir "neck of the 
Ikimi' -hoiilil Ik' miiri' fully 
iliaiiril. Ilii' li'iiiliiii^ M'|ia- 
latcil. ami tin' liili' nt tlic 
fiiri-c|i.s |i)-cssc(l innrcsccim'ly 
mumi the ncek of the iHine*. 


k«,i n»i I 

life of the Dttticut. tt» tlu' traiwv. IS." lixaiiu nl W inw • 
5£t!!dl5i Wakened, a.u. tW ... n. -^;;[; ' J;,. ehe nu.tila- 
Bvit where ttDD«ir»nce w th.- '''''•^^";JT th.' Mi.|.r..xinu>ti..n of the 
tio„ is to he huWen m much as ,..>ss,hle h> '1 \. ,„„r„w-hla.le.l 
the h.-a.l of the -.o,.e « -"'"^ VST;^^^ the seetion sl.ouM 
s«w or hy hoiie-fon eps ' ( M,m\ foi 

be made ohh,..elv f. ' 7, ^t^^ m^^^^ -P-t. «" ^!" '' 

8„ as to ren«.ve more .m ' , ,„.,form {UH*rticulation. 

caw«, after «Uttl«.proctice, It » not > t l^^ ^i,,^^ 

H..vere.l aft.-r tlr' flaps have 
iK-en ihssect.-.! upwar-ls to the 
proWT level. 

Here. t«M). care must h." 
scrupuloiwly taken not to m 
tcrfere with tbe tiwues m the 

*'"'"\'ft. i icnioval of the finper 
an.l the Ksmairh's bamhip'. 
„ne or more aiflital vessels lyinj; 
ratlier deeply opjMwite the w. l. 
of the finger will require hga- 

In the case of the thumb, 

index (Fi-s.20an.r-' I), or little 
tin vr the strni-jht part of the 
„va! incision should l>e l)la<''d 
to the uhiar side of tin- mel.i 
carpal bone, rather than ui the 
dorsid mid-line, aa the hnc of in- 
cision will be better concealed. 
In these cases the saw or honc- 
foreeps should 1h> api)li<"d ob- 
liquelv from without m wards 
and from within outwards re- 
spoctivelv. so as to leave no 
projecting bone on the radial or 
an.n«T.»...~. - „h,ar aspect of the houd. ami. ui 

the ca«e of the index, toallow of thothiujb l.ein, r. 

to the secmd finger. I* »»»>' 7^*^. ti W^^^^^ the a.l^acent 

with regard to the after-treatment : to cross at 

fingers too closely or too ong ogether, "the'wisc a tuKl n ^^.^ 
their points will be noticed . <2) I" ^'^ """^^^^^^ ^^^^^ or 

articuffions where, in spite of copious irng^^^ ^nJof be got rid of 
other Bolution, a co-existing mfec ive ^"'"I't '^^^^^^ °^ ^ 
with certainty, the cartilage should be removed^ ^^^^^ 

Tedious cxfoUation ia otherwise certam. ; • 
should be noclose suturing in these cases ^^^^^ X^ai Z a^^^ <>* 
be emplov.d from the first. In this and many 

. W ill, 1... ,,rocauti,.n uiv.-n at p. .12. A '<»'^%»^-'";''"X,u'^";I;:^^ .vro .•nlaru.-l ia 

■2 vL- sh... 1.1 iH- tak. n t.. s**ure /'""^P^- fow hour, after 
any i„H,u..matory c.ulition, othorwi«e ptofune bleeding may take piaee 

the operatioii. 

Yir. 20. r>|.nl^itini;llH' 

.. al joints. In th.- .•«»o ..f thr thwinl. a 1....- 
n iliiiar llap lia« lH-«'n mniU- ; in tli.' iiul. N a |wl- 
; ' , ''xt. rnal H.,. : in th.- mi.l.U.- HnKj-r a 
,.ir. ..lar in, isinn .oi.l .« straight .lors.-, <•. t (n ati..M ..f tl..' m. th.Ml .» r„.,«. / . ) liav- 

movea l.y ti" lat. ral lla,«. an.l X'^^r^ ''' 


Imiul. pfrfurated «iic, which can Iw ••usily ImmI.mI. is di.- Ii.-sl inat.'iiHl 
ft»r Hpliiits. 

Diiarticnlation by • Oiiwlv ladsiOB with • Straiiht one on the 

Dorium (Kif. JO). Thin niotho«l. a iiMHlifiratiim of the imv ,„ r<i,iii<il, 
is i.r. f. riv.l \>v Fiimhi'iif us .sim|.l<'r aii.l sat iiHciii}.' skin. The huiid 
iM'iiijj . niii|.|.'t.-lv supiiiatt'd. an.l th.> oth.T tinp-rs licnt out «»f the w«v. 
the «uiu'<''>h cuts ucnisM tlio root of tin- »in>;fr in th." di^'ito palmar fol.l. 
iftiinK t" JwH.'. and .Mu roachin^' as far an possilil." on tli.' sides 

<»f thi* finpT. The hand \mi\ii pronated. the of th.- 1 in idar iiii ision 
art- proh)n>;.Ml up to the niidille line of the dorsal axjM'ct of the tinker, 
wh. iv a straight lut. b«'>finninK u little above the level of the joint, w 
dniwii to and |).-rp.'ndi( ular to the tirnt. Bv thia meana two riRht- 
ii.i^'l.'d flaps an- niarkod out. Thes.- are raisetl ami the Imwo illiwrticH- 
hifcd. Iiv the .steps already ^'iveu. 

Ampntation by a Single Flap. Where, owin^' to the state of the .solt 
iwrtH. this method in re4uired. Kij:. 2t» indientes how it may lie emjiloyed. 

AmvnUtion of a riagw. togetlier with Removal (complete or partial) 
ol its Metaoarpal Bom. This operation in eauly |H'rformed l>y a inoditi- 
cation of tiw method en rwiueUe or that by lateral tluiw jiwt dm ribetl. 

Kwi. 21. Ani|mUti«m of little finpr ami itH mHikrariml 
by thi' oval melhiHl. 

It is only iieeiiful I proion" the dorsal part of the former incision or 
the iipex of the latter as far as the carpo- metacarpal joint. 

l)isarticulati(Hi. when the parts are much swollen, will lie .safely 
pi rforiiied here In carefully proloii<;in« luu k the dorsal iiu i.sioii in a wound 
kept bloodleaa till the "joint is felt and seen, suitably manipulating 
the finper ho as to put the structures attaclied to the metacarpal b<me 
nil th.' stretch, reinemberiu}; the insertions of tendons into 8«mie of 
these bones, seyerinj; the lijianients »)f the articulations with careful 
touches of the knife, and not siiikini: tins into the palm for fear of 
wounding the palmar .synoyial sac or the deep palmar arch. Wliereyer 
possible, the extensor 'tcn(huis shotdd be drawn aside and carefully 
prcjferveti. In infected cases, the greatest care must be taken, c.//. 
irripition with sterile saline solution or with a dilute antiseptic lotion. 

Ill the ca.xe of the little finger (Fig. 21). the ulnar border should be 
( hoseii for the incision, or. if the dorsal tissues are much daniaged, a 
palmar and internal Hap may be made. In clearin<r the metacarpal 
the knife-point must be kept yeiy ch)se to the bone. If only a 
portion of the bone needs removal, this should be divided with a yaw 
and not with bone- forceps. 

Farabeuf gives the very practical hint that primary union should 

« Mamml oj Sarfiml TnalmnH, vol. ii. p. 514. 

sl'KGERY 1 S 


he »«-ur.-.l l.v th.' Hups m.'otinji rea.lilv without tentton. Otherwise 
the <oi>trui ti..n of th.> scar will draK u|«.n the next finger, and came 
itto8tickoutfromitHf.01(.wsinavoryu|.'lv(a>*hi.)M. w-t«m 
Where a inctacariwl bone is n'lnov.'d f«»r Harcoina, Mr W. wawon 
Chevne and Mr. Burghard ' advi«»' that th.« adjac'iit bon.-s on,- or 
both aide, be removed aa well, to avoid tho risk o leav.nji .bs. asj. 
behind Thev add : " When more than one metacarpal bone is r.'mov«>, 
it ia well to take awav at least one finger in order t») preserve the lul 
ow of the han.l. I nlesn thia be done, the fingera are apt to be erowdc.1 
together as the wound . ontracta, and conaidenible mterference with tueir 
uaefulneas niav ensue." 

ABtalitIra d two or three contiguoui Fingen. \N iieti (a very rare 
contingency) two or more fingers re,|uire removal at tb.- sanif level. 
,>. througS their metwsarpo-phalangeal joints, or higher up 
racquet or lateral fUpa may again be employed, the apex of the doraa 
inci8i..n starting between the fingers when two. and over the central 
metampid bone wfcen three, fingera have to be removed. 

AmpntatkM ol PhiriUlCM ol Thumb, V.>ry little need be saiil ab„ 
this operation, as it is very rarely p. rforined. Owing to its numerous 
muscles, the thumb is extremely ii.obile, and thus escapes injur>' 
Thanks to its abundant vascular supply, trimming of the soft par* 
after an iniurv will g.-neralh leave more of the thumb to oppose to 
the fingers, and thus is to be preferred to any set operation. In rases 
of necroeis after whitlow. Mr. .lacobson has twice removed l.otli 
phalangea, the soft parts consolidating usefully' with the aul ot the 
Urioateum that was left. For further remarks on the imi>ortance of 
preserving the thumb, see Excision of the Thumb, p. bH, and ( .>n- 
servative Surgerv of the Hand. p. 70. , . , . u 

Operation. Amputation of the phalanges of the thumb may be 
performed, in the case of the distal one. by . long palmar flap, as in 
the ease of a finger (Figs. 14 and iio) : of th. tiist phalanx^ by anten- 
posterior, lateral, or a modification of thecii. incision. In the la t r 
case, a short longitudinal incision should be made on the radial rathe, than 
upon the dorsal aspect as in this way less damage will 1«. done to the 
tendons. In anv case the incisions should be came«l well on to the 
phalanx to ensure sufficient flaps to cover the head of the metacarp^ bone, 
together with the sesamoid bones, which should never be removed. 

The line of the mctac ari)()-phalangeal joint is ver)' nearly transverse, 
and lies just in front of the knuckle. . i r 

After amputation of, or through, the phalanges, the s( \.re(l end oi 
the long flexor, previously cut long, should be carefully stretched into 
the angle of the flaps and to the extensor, and also, jf possible, into the 
theca and periosteum as well. , , . . ,v w 

Amputation ol the Thumb at the Carpo-metacarpal Jomt (nps- i'> 
and -22). Indications. This operation i.s rarely called for on the living 
subject* Gunshot injuries, some growths, especially chondromata ot 
the phalanges and metacarpal bone, epithelioma of a scar, and melanotic 
sarcoma occasionally call for it. 

i This wHtronulv in.lii aUil in thc.«. casos where it is especially important to leave the 
thamb hnit for hi)l('liiiK a pen or any tlelicAto inrtrument. 
• It ia not infrequently used as an eiamlnatkm te«t. 

y iriiciiin uj» iiH" iiii-i.i \ 

i|{t>r ulonK itM inner und ii 

tcr iiii«r):in. thi' tlnuiih \ 

tfil Mriil aililiictt'd. Till' I 




(iluMtiim Tho | <>f tli.- j«Miii l«'tw.'.'ii ili.- traiM-ziuiu ami 

littiiw int.. r.i. li oiIkt I.x .iiiitii;il . ,,ii|.tati..ii. una th.' iMWtioti 'rf iIm' 

riulial «rt.'tV |,,.>.Mhl.' .'V.M tin' Im. nl ll.- .ivln,,! pmo-. ..I lll.- >a.l.,.s 

iiutt al>'>v.- thin iKijP*. 1"^ an'l ait.l an»in. whn. iH'tl..r>ti.»i.' tj«- 
first iiit. r..s.s.-uuii space. Iyinj< vhmf t«. tlw inetwnMnpiti Ihhm-. ni«* 

Tlif owTiition ift iisuiillv |M'ifonn«Hl by u iii.Hlitnati.m ..I th.- mk'IImmI 
rwi'irltr. All Kmiian h s l.aii.lMKP. <>r touriii.|ti<-t. havniji l»wn u|.|iIm-.» 

aliovr til.' wrist fla- liaii.l li.-M iniilwiiv iM-tw.-.-i, pronation unrf HUpiim- aii.l Ih" llimnl. Ii-ld ..v. i c'Xt.'iid. ,1 su t.. n-lax th- pHfts. th.' 

siirj.'.-"ii iiis.'it.H til.' ..I a -In.njr iiain.w -.alp.-l jiisi aJM.v«' tin- 

jitiiTt. Tlii< i" lull liiif.x'i"'* lir.M.ltli li.'l.iw 

tin- tip of tin- styloid pr.xfss. Its poNition .an 

iwiiullv Iw madf" out Ity tracinn up tlio iii.-i i 

laipal liiilit' with oiH' lihjp'l 

till' llimnli alonv' its iiutci 

li.Miiv' alt.'niat."l\ aliduit. 

knilo. cntfiin}.' th.- iiair.>\\ int.Tval l..'t\v.'t'n tli.- 
tendons iif tln' .'Xtfiisor .>ssis ni.'tacai pi i'li.l iniiiii 
iiitirnmlii, should avoid /« " t<ilMilihnniiitin)i i/o, " 
and the radial artery. Where then- i« nii«di 
sw.Iliiifz coinpariwMi nuwt be nwdi- with thi> 
sound tliiinih. The inrision in then rarried aUmfi 
til.' d.iisuni .>!' till- lioiif as far as the tmneof the 
(list phalanx, wli.-r." it passi-s (in tii.- cast' .if the 
li'lt thunil)) ol)ii.(Ufly to the ubiar si.i.' K.'I.'W 
the web. und tlieii aroun.l the palmar asp.-, t .if 
the phalanx, aUin;.' the radial side, to join tli.> 
dontal infi»i«Mt again. Taking up first one ed>{e 
of the inci.sion and then the other, the mirgeun 
dis.seets up the soft jmits fr.ini the bone, keeping 
the knife-point <los.> to this, csii.'cially on the 
inner side, where it is in close pro\iniil\ to ili.' 
radial artery. The extensor teiuloiis ami the 
short nuisile.s of the thumb being severed, the 
joint between the trapeziuni and the metaiarpal 
bone is felt for and opened from behind, the 
whole thiinil) beini^ stroiifily flexeil intothepdbn: 
the thumb is now lenioved by putting the remainiiiir lisse. 
stretch by twisting the metacarpal lione in diOcrent direct; 

Amputation of the Thumb at the Carpo metacarpal Joint hv Transfixion 

{Viji. ■2-1). J'hf hand iH-iiig hcl.l as lirf.irc. ami ih.' imUs n laxi .l liy sli(,'lillv iiil.hi. titiw 
ihi- tliunih. an incision is made (in the i-a.s.' .if lli>' li ft Miiiiiili) fnuii the Im.s.- of tin- 
ini taiiir|iiil bono rather to its |ialinar as|H( t. aloin: it.^ (Iiirsuin. itiil (In ii iililmui'ly 
t.i tlic iihiar »i(k- of the liasi- iif the lirst plialaiix : tin- Uiiit'r. a loim iiaf nw lii..IcMirv. 
IS thi-iiimslicilfriiiu tills |Miiiil, at tlir iiim tiim of tin' unh tin' tlininli. tliriiu«li 
llii- llii iiar . iniiii nio to thf imiiit whi ic tlu' in( i>ioM ^larti .l. over llic iar|Ki-Mi. !a- 
. II |ial joint. 15v Liitliii« outwards, aim:!; the lint- indiiat.>.lin FiR. 22, i» ih formwl 
of the tissues iii the hall of th.' tliiuiili. the knife iH'inK kept floHe to the ittm' i»t 
lirst. hut directetl more suijerlicinllv afterwardn as it vonnv out through thi- Hkin 
ovir the sesiimoid hoiuf) and Inise of the first phalanx, to prevent its iK-ing locked 
l« r»'. Thin thip lieiiii; held hack, the metararimi U>t\<- is .IisHc< ti><l o«it hy keeping the 
knife done to it. the joint o|K'netl. and the thumh renmv.'d as Itefore. 

(hi the right side it is better to cut th«- iMhnar Hap hy transtixim* lirst. iiiakiiig 



digital branch^ »hotthl require ligatun-. 

I tnt .l removal of the thumb is one of the rarest amp ta- 

'p"r n n ml b<.ne shouW always be left if V^f.. 

1" f n- t il »• ..... t UHoful wh.-n the finders are opiwaed to 
I't 'TlLtt flexor slu.uld always i.e sutun.l to the theoa or otherwise 


B.mnvftl o! Phalanges. < )vvii.!.' t<. the .-xceeding value of tho thumb 
Removal ol ^"^aianges - jf not only m whitL.w 

a phalanx / ; ' i ', .„ ,, phalanx when it is the 

neerosis. but m th ■ .a.." ' ' ..arance saved by less 

ST! • r of Si ;x v^^' 1-7-'- 

mov. i.i. iits iind for WTitmg. ...M ralicm on a patu-iit an.-<l XI The 

In IH«7 Mr. J "//v. ^1 "ingle lorsal ineUion, for an 

,i„t phalanx of the .'is. of tla- distal one n^-ted for a 

enehoi« r..n,a of H. xor was stitch«l to the portton of the 

himilarl.nt n.n. 1. .-•nal U r Kro«tli. ' '< , ,^ ^..jive and pa«8ive 

r;;^::r«S"'r;:r;; i3;j^:-rin^t3;'h ... 

p.ifr". p.":!^-et^^^^^ a part of such value 
as the thuu.l. „„,..f„urth of an inch beyond 

.abject., tl..- '•1>|1;I">>'' ' ' I n,,- |««itioll .If the tadi.1 

I l^iu-rl. 187a. vol. ii. p. *»«• 


uch sho.t..,u.a. At ,.. ss it is ,H.inf...l out ... sm,.- .as.- 
n" 1.-.S doeplv situated i.i the pal.... a «lo.sal .n.-.H.on a...l i-artml 


!.'"!'. . T\!.i t:.-. ftinfnti •nd Hiimr st the Met^ct . 


R^iu i£n of Dislocation, o! Thnmb ..d Ftofw .t M«tf«*'P^ 

Dhalangeal Joint. Excision of the Metacarpo-phalangeal Jotot The 

fSTlL .net with i.., a „...tarar,.o-,.haIa..| f 

he rase ..f the thu.nh has 1..,.- h.-e., n.,...^,..s.Ml. M.-. Hatth- has 

in tlie case <»I inunm n"" ■•■■■ji , . 

I,^.with instructive cases' that like .litH...ltv. .hu- to -""1- 
,nav. thoueh more rart>ly. he .n the . ase of a t. n^er. esi-e. .a 1^ 
" ii..h-x. ( (ther paiHTs by the late M,-. a...l Mr. S.v„.o... s 
„„lMr. .L.nia.. L1..V.I' will repay peiusal. A»y- "/ » 

|„|l„wi...' factors n.av l.e th.' cause of the dithculty : (I) I he 
„ tonh:.h-likc slit with wl.i.i. the two of the flexor brev.s ..... 

heir Ul...oi.l LOW. il. their alte.c.i rclat.ol.s. en. ..ace the hea.l 
of the .netacari«.l bo,.e ; (2) the lateral li,a...e,.ts : i;;- ;;;;' 

of the torn anterior or glenoid l.etwe.-.i the base ..I tl..' 
an<l the head of the metacarpal Ume ; ( t) the co„tract,o.. ..I t l.e .......coi.s 

nuiscles around the disl.K-ated joint; (5) the sho.t..ess ol the leve.afre 
onlcl l.v the .lislo, ated : (.i) the tend.... of the flexor lo..gUK 

,H.llicis ...av 1..' .lispla.-.>d a...l for... a te.,se band to the Ri.le ..f 
he joint. wi„.li..- round the neck of the ...etacarpal. he .h.ef ca.ise, 
however, is the displacenient of the }ri..„„i.l or h-an.ent of the 
cariK,. metacarpal joint. This struct,.ie. wl.i.'l. .s a plate ol I. ... - 

.arti'ttce. occupies the interval between the lateral l.^ranients v . 1. 
which it is cont.nuo,.s on the a«p«H-t of the joint. It .s .nt..n..te y 
,.„n..ecte.l with the sesa.noi.l bones. a...l. while ..n.t.'d to the 
„|,.,la..N .s but loos.-lv attach.-d to the ...etacarpal. V> h.>n dishK-atio.. 
|,M,kwar<ls occurs as the les.ilt of violet l.vpe, of the ]<..nt 

the .lisplaced phalan.x tears tl..-..UKl. the weak attachment, .arrv...^' 
the littan.e..t backwanls with it over th.- of tl..' metacarpal .....c 

RememlwrinR then that the a.iterior and lateral l.i:an.. i.ts i.........-; 

on,. stnietnre aie the chief inipttlimenti to re.l..ct...n ...ani- 
,.„lati.... sl.cul.l b.- tri.'d first and always with an a>.a'»th.'tie. .. he 

, isr of a ti.ificr. tl..- .lisplace.l phalanx is w.-ll tilted back ..n th.' 
,l.„sun. <.f the ...etacarpal. in' to l.ri..^- the «l.'..o.d l.nan.c.t an.l 
other stnictures ...e..tio..e.l well ii. front of the a..t.M....- inai^^it. 

of the articular surface of the phala.ix befor.- fh-xion is e,,.pl..y.M I his 
with fir... pressure of the thumbs the base <.f the .l.spla.'.-l 
nlialanx. iicerallv oa.ises it to slip into place, l.i the case of the 
'ni.iction S1.....M be tri.-d on the same lines, the wl.oh- tiain.b b.'.i.^' 

first a.hlu.ted towards tin- pal.... The displa.ed pl.a!a..aes n.av. . 

nec-ssarv be -rasped l.v sped forceps f. nive nivat.'r leveiaL-v MiouUI 
n.a..ip..ratioi.'fail, as it ve.v lik.-ly will, o..e ..f the tollow.n- up. n.t.ons 
sliouhl be e.i.ploved : , , , i . . 

il) Tewtlomii. A tenotome is intro<lnced o.. the .h.rsal asp.-, t to one 
si.h' of the niid-li..e so n« to avohi the .■xt. ..sor l. ii.h.ii. It should l.e 
,;,n„ ,M,.wntothebasc..f tl.e phalanx and th.'U be n.a.lefon.t upward.-, 
alonn the k of the ...."ta. arpal Ry this means the glenoi.l lw»»<«'"t 

will be split longitudinally. A r.i" t.t.on of the maniputotioiw will then 

< Lanfrt. V..I. ii. p|i. I2TI. . ., . .™ 

» Ihid. vol. i. p. mt. * i""" '• * '• P 


>r<'n<'raHy hr Hiirre88fiil. OrcasionBlly tho tonotoniy knife is iiititxhu-cd 

on each siilc of the extensor tendons and. the ])halanf;es i)ein^' extended, 
tlie stiiictnies lietweeii the liones are divided transverselv. in this 
way tlie sliort tl( \or js eut and unnecessary dainaye may he done. Should 
the Niiupler pDK-edure fail, it is better to perform an ojhmi operation. 

(2) Btf a Piihmir Inrixhn. A median incision two inches in h'n;;th 
18 uiade over the anterior aspect of the joint through which the head 
»»f the tnetAraqial is freely e.xjiosed. If the tendon of the lonp flexor 
has slipped to the iimer side of the metacarpal it nuiv be rej)Iaced by 
means of a strabismus hook : the tendons of the lle.xor l)revis mav be 
iiooked aside, and the torn jilenoid liixament ma\- be drawn froiti between 
the articular surfaces bv suitable hooks or forceps. After e.\tensi<tn the head 
of the bone can then be replaced. If po.ssible a few ewtftut stitches should 
Im> used to < |ose the t«'ar ir> the capsule ; the wound ih then cUiuetl and 
the thumb put tip on a perforated zinr or a moulded splint. 

(■t) Bff n Iktrnal hi< isiini. The dislocation is exposed bv an incision 
to the radial side of the dorsum ol the joint. The irlennid li'Mnient caii 
tle ii be re])laced and any tense imnd be divideil. The want of room 
and tlie close conn<'ction of the .'xten.soi tendons with the causule always 
render this small o|>eration one of mmte (yficuity. The p»ltnar incision 
should, as a rule, be employetl. 

(4) KxH-sim dJ the MH«e'tr fat- ft/t'ifaiMfrnl Joint, fhin is especialh' in- 
t^4ite<l when the disl<K"ation has remained iiiirediiced tor .i lun<_' time 
Thf head of the nietacar|>a1 should be ex])o,sed throne' .i palmai iin ision. 
.1- desctdird abiiv.'. The -oft parts .He freelx' retraitetj. end 
ol t lie ilispl.ieeil metacarpal liavntiT be<-ii cleari'cl by keepin;: lie- kw4'- 
jH»iiit closely apjilied to it, suflicient is then reiiiwved «• iritu by a narrM« 
S)iw. which IS preferi»i»4e to iMiiie-fon-eps. Free ri'H'tion {)f tlie oiw 
lH»ne will probably siifB**. if suffWientfy free : t»w*w4y fiariiiji off the 
artk-ukr cartiiajre is likely to lead t-. a stilf joint. Onlv it;.' to the 
anumnt of inattin;.'. or pre\i<iu.- inttaamnation titere be aiiditiotiid risk 
cil ankviosis. should tin' bas.' ot tie- : rst jiliaianx 1m' icmnx'ed a- «eP 
( are must be taken. Iiefiuc this is ii"«tie. to (i»'t»i ti carefuliv. as cum, 
pli'te|\ a> po,v«ible. tlie tendons in.s»^e<l info tt fojrether with tin 
periosteum, and since two tmshly sawn .-rtirfwf* are left ad4itit»(Ml 
pref-autions nmst Im* taken ufrmm^ ankvhim Any tendwt a<>r-i^«>ntaN>' 
cut shonhl Im- sutured '1 lie |»atient iinist be |irepare.i for' slRi*rt«tt- 
injr. esiH-eially if the epijdiy.-is of the phalanx has been temosed. 

ooraiBVAnvE suKmssr or the wMm 

While each case rei|nires indnidual coiisidetation. if is boped tlwt 
till' lollnuiiijf hints may be o! .sei\ice to the sur«eon when called iipfm. 
sudile:ily to form w hat is a very im|M)rtant decision. 

ill /■/«' i/iuMiim iij Irifimj to unit*- » tot4fH§ m-fmmtrd purl n« alluded 
to at p Ts. The ipiestiot) of palmar hR>morrteif(f is ccuiKitlwed at 
I' -"^ •iiid the ti'.itineii* uj injiiiies to tendons uihI owes will Iw 

iumiil llielel llli'se h.' i'liiii_'s respectiv . ' 

1 .\f!ei inj(ii\ . \ ipt in rare i , • h.-re the combined ...m- 
miniiiion of Im h. injiirx- to tendons, and strippintf "ff of skin is extreme, 
iio sil luiijiiihit:!!)! IS to l»e p^'rfonned. hi tin- case a f«rt of .such 
iwalculable value, and so ««'ll suppled with blood as the It.ind ttie 
Bsipeoi) should reinendwr Verneuil's words .ind not " apprtiacb lie -i' 
cases with tfee bistoury." He is to ren^r th*- part iw aseptic 

t^f»issitT.«Tra m^WRfXY m 'mm ^ 

iHwsible. a«d tihw to wait a»i<l wafth what XakMPc mi\ *i f«w»ar(l.s 
III)' uHimtttr n sUinUinn of um§tdHeiuL Tkk. <d vmrnm. mtaih rit*H of 
suppuration, wlotifihinj;. and <'«»h wow nniui. flM!hwtataaM. _ AwiiiiiiMin- 
att<Mitii>n tu tlif a<lvi( <> at p. ".'5 ahuM" jnstilmt maaiBictilwiP mkm. 
Spt-akni^' (TfUfrallv. thew t-asfti. m wlwek tke iliiuiwnn fcas 

fall into two >;rou|)s. 

A. Injiiriix Itmihd to *»! Fin<iers. Ht-ri- conM^rvativf sni<rrr\ is Icsh 
risidly incticated than m eonpliratMi aud «>xt<>iiHiv«> mjuneH to th4> 
hand. If *e mjray t« imfer. i-w p w c iaity tl» tWf* or fourfeb. be 
stich that u.Hf>ful fum-tion wM he loat. tt mU wmer to aniput^ it. 
anil not iiold out anv iiop's of iiwftjlnwwi. wMril wt1l*mly. aft<'r prolnnfud 
and triiioii- tn-atinciit. provi' illnsiv If ir tin' index which is most 
ilatm|!»tl. rhf suPfjetHi will ifimMnlx-r that a lii'dy nmvablc middle 
tefeer will steadily impmve in shannj; with the thumb the loss of the 
tndbx. Ab«1 if the head of 1^ nM>tacarpal bono lam been removed, 
H mm iiiteBJiiiiitel apmi>e wWl jptotocHv Ik> developed, vhieh mmy hf 
ven- iweftil lor a working mm\ 

B < 'imi i>lirf lied iinHMi^trnnf injuries to the ftmd. Hew tfiP difficulty 
of estiniatnij.' the extent ol the daiiiii«re. the power i>f idtinuilf recovery 
in a part like tl>e hand, and the ainoimt ni loss ot tuni-tinn tofiether 
with th«» li«»|>eles(«HesH of anv leallv u.sefnl artilieial substitute slnndd 
make cwwiervatiw stwgwy the rule and the Murp'on should wait and 
.mn* how mmek a nt i i i cpti e baths and dressinfis. t<«j^her tlm other 
aids given bekiw. will Have from tlestnietion. 

(.?) hitrr Atrnft^tiou. But while it is a eardiinil principle to pre.servi- 
ever\- inch of the liaii<l. a single tiiiL'er or a tlminb alone beinir far more 
ii.sefid than the niost I'laborate artiliiial limii that can be niad«>. and 
while to };ain this end it is fre<pieiitl\ advisable to trim up an i ijiired 
part ami to reinr>ve bone in prefereiu e to ihnwfr any .set amputation. 
It must always be reinend)ered that <i juirt mail /«■ roiMdilr of lifimj saved. 
<md ifet nltimntflii lie nxeU-nn iinlrnn U (m- iit leant uaHiaUif mnrahlr. .Again. 
Ml3!^^v of a part, at first itromisins; in usefulness, may set in some 
t«Beafterthe iiijuiv. iiKiiiLdit l.iiMrcb b\ trophic disturbances. In either 
of thew' cases a iij^kI cical i ii i,i IK ronlia< tcd claw, or a pointed, sensitive. 
am\ shrunken part ma\- call, later on lor .iiii|(Utation 

(4) Aimmgst the irri/ ij-irfifiiiiiiil nixix n-hii-h inll for jir i nun ij n in pitta- 
are those where (1) one or more fin^'crs are manuli'd anil pulped 
ait >'i all shape or recognition ; iJ) where all the tendons are torn 
'i foils;!! especially if this lias hapiiened at more than one friace, as in 
njierv mid in tlie palm also, and where, with injuries, there 

1 h 'f'- nwn of the |oints as W'-ll as frai ture of the bones and rippiiid 
ii- -Ktii !.■;• where the liiitrers are exteiisivclv -|i|it loniritndinally ; 

■i- «no r coirtiltKUi. which .surgeons in laij.'e maniifact nriiie centres 
iBPm rer»»»*» *• Hwet with, re<|uires grave consideration. / <■. where a 
k»i if lUv««4 Mvmg t*» it*t having iM-t'ii caught Ijetween rollers which 
*ff*i hut fin «•» : here, as the patient draws back, the skin is 

-irtpped oil a 5lo\e, from i he u I ist If. in addition Ikiiics are 

rMahtnl tl" >r theca' opened, i'lnpiitalion. ie.i\in<.' |mrt of one 

te^pnr. d li,. '(nit*^ m> int.tct .,r tin, w^h the w list -joint .vhould be 
p t f fo n ae d at tme ; and Billroth ' advises this ste|> where the skin is 
p«m»ph»tp|v .«««p4ird a§ with<»at tiliier ii^wv. fingers entirely depriveil 


of thoir skin iilinost itivariiilily becoiiiiiin gangriMious. and the n-sult 
l)*>in(; " unil<>r tlio most fiivimriiltle circumstances, nothing more than 
an unwieldy cicatri8e<l stump. " 

Tkf Mhmnfi caae ' is a good instance of the above : 

"Tlir Imiid .)f a littfc> Was cinijflit ill the rolling iii.icliiiir iif .1 liaki i \ and 
flic Nkiii (lividi d at lln' wrixf jiinf as clraiily as if it liad Im'cii doiw liy iiit( mIhpm. and 
an i-iitin- kIcim- of tlic- skin taken "If. Wlirii I saw it. it was licid iiii liy thr ti|is of 
till' tiii^i'i'H only. Tliri'i' was no injury otiirr tliim that (k'scrilKil. I felt satislird 
that iiin|mtntioii was |iro|M>r : liut the jHiticiit iimiHtt'd that hf wan wiUiMft to t«l(e 
till- rink if nniput.iticni was not |M-rf<irfiii-<l. aiiil I replnn-d the fl»|i. wild HtMicd it in 
H<*vc»t pfaKtw, Mieving timt >t would ittough. It M Hkn^. iind he {ert faiH tiniirrH 

to the klwckUn, bimI the <mly jwrt that wn» mvet\ was a Hinall jiortioti of the 
thtimi). Mid Mm* ni<'tarar|ial |M>rtion of the hand. This, of roiirsc. was a ciiatricial 
Hiirfim>, wilich I rovi'iid with grafts, and it liiially hralrd. 'I'l» Ih>\ can liolil a jH ii 
in » iittk> gmow far llu' Hidi- the thumb, and it i>< probnlilo that thi> n-iiuumt <»f 
the hand wffl timiftiF licf om* wni^ld. * 

The espfauMtion of the ct-rtaiiitN' with whicii the sti'i|i|)(Mi-i>il' slan 
dim in th«»»* vwmi. ami the of the most careful st'tcliiii<;. 
lies in l^e Utiet thttt mat only have the ve.-isels jMissin^; from tlie deep 
{)att»(w tke-flHiB beeK^otii through, but the skin itself has lieeii subuiitt<^:i 
to iiii M»«rmo«8 strain and drafiginj;. In such cases where it is Hear 
tlir i.'ln\ I'-lik" skill must fjo. liut tln' deeper parts are miinjiired. an 
attenipf should Im' made liy skin-i.'rattiii<;. after Tliierseh's iiietheil 
(.we p. 42). or liy iN'iiiiMculated llaps tst'i ji. 74), t«» provide a «>veiing 
and prevent the sloughing; of the deeper part.s. 

(;"» Skiti-jrulhtu/ is <'spe<ially to he made use of where, after an 
itquiri' to the band, it nuiy he possible to .save one or tw.> (infjers oidy. 
*tr. partieularly. the thumb and index finper. by takin<r skin, if po.-isil»le, 
or a pt'duiK iilateii llap. from the dama<:e l hand, the op|Misite arm 1, the 
al:<4«> iM-ii. Ill siiifhter the larfie i.'iafrs taken liy Thierscirs nn'llioil 
ii/.i.) from the arm will he employed. Dr. Schreiher- advises skiii- 
gniti^ in smaller injuries. Thus, if the skin In' torn awav from the 
doiMHK of u finger, over-extension will follow wIh'ii the wound is healed 
u n i m it is grafted. On the other hand, if it be the pulp that is torn 
aw»r. sucees-Hful ".'raftiiifi will f;ive a rounded, .".ensitive. fleshy end. 
iiist'-ii'i of a thill. -I'lisitiM' pointed oiii-. The sur<.'eon must, of coursi'. 
pri'pari' his patient lor lii.-appointmeiit . The f;rafts may dn'. and the 
in]ii<-<'il purt III redm ed to a daw. aetive mo\i'ment lar{;elv dis.i j)|H'ariiii.'. 
J*km-grafting may made of later on if oih' or more tinger^i 
btmnie contraft4Ml. and division of the cieatri.\ leaves a gaping wound. 
The above remarks refer t. skin-grafting for small areas on the fing«>rs, 
and the bark of the hatuJ only. The ease of the palm and the emplov- 
nienf of pi'iiiiiicnlati'd flaps is referred to later ' p. 71). 

In .sonic- fiisi'.'- till- :;iefhod "f rlrsitssoticut of Kh'II' ll siir^i'oiis will 
be useful in >iip]'|i'!"' 'itiiii.' or . "-phi. niL' .--kin-graftinj;. Supposing.' that 
in a case of .severe laceration. 111 whseli it i.-^ determined to try and save 
the hand, one finger reiptire.s amputation, hy turning out the bone, 
remo 'ing the nail ami tendons, some of the .'«>ft j)arts thus left may be 
uti'ised in (illinix n|i an\ lart'e "^'p '"'tow . The iiwision. 1)1 rint'ii tti . 

I- liriile alnlii^ tlii' iloi-^niii or pallp;ii .isp'Ti .icn ■.iii|i_' as if is il(".;ii'd 

'hat the soft jiarfs ot tlif li?ij:rr shoukl inll 11. to place along ihc Imck 

or front of the hand 

' Itr. tiri-porj. tif St. Iniiis. CS. Trnnn. Am r. .v»«f .^«^»■.. vol. 2. ji. 232. 
.W««c». Mr'ti. Woeh., Auit IH!»2. 


Mr. ('. li. Kfctlcv. \vli..s.- infi. nuitv is well known, nmde nse of the 
soft parts in a ilitTcnMit way.' 

A v«i...p »•<•""•.. lu.l all tli- lin».'. rs ..f tli. riKl.t . rusl,. .! 

.V^rr-pl Im j..i"t «as .;,K... on tlir | a.s,KTt. All tho I l.-xor tondpiM irf 
h , I m.l r MK lin«. rM mr.- .lot rov. <l. U 't their (lornal U-mlon« wm- intnot. 

„ ,; ',. l., 'a,..h. n.,„,.l an.l lix.-.l to tho prfvioiu-ly n-fN-Hh.-.! ,wlm«r ««.rf.KH. o 

li';,';" «( lk.x.m. «f H..- .ui.l.lU- li,.«,.r. The r«mlt«. both a* r.ipi«U a,.,«-a»iK-o 
;iiiil fimi iioM. wrri- xHrprisinnly K««mI. ' 

((>) lni'ir'i to ./oi tils. Wli.T." til.' t..'iuUjn.s nr.- uninjur.-.l. ..r can l.o 
mitiin-.!. wh.Ti' tluTf in no .-xtcnsivo (onunimitiori cf Ixm-- <t jir.-at 
i„l„rv t. . th.- iddn. tho finn.-r will. ..f rourso. »).• sav.-.l If .'xi).-.tant 
tr.attn.-i.t is a.loptP.1. .'v.-n if the l»art8 heal .luiikly. tli.- si.r};.>..n vvil 
I ,, fortuiiat.' if li.' nwna}!.-s to pre8Pr\-e for his patient half the natural 
n,„.'.' ..f m..v..m.-nt ui tUr joints atTcctod. And. to do thus. Huhnts - 
,.l nerforaf.-.! zni.- tn-t oi w.mmI aloni' will have to Im' fre.iUfntiy chanfjed, 
tf«* part iH ini; put up for a shert time, llexetl. then extended, maasage 
iMwiduouslv cniploy.'.l. it.-. , , . , , i n » , 

FrobaWv exrisioii of a joint which has Iwoii freely op.-n.Ml will ivsti.r. 
iMtt.T inoN-ewent if tlie patient is hrave and perw«venn>i. It shon.l 
..Mtainix- Im- wied and rwnoval of the b«»nes carneil out siilhci.-iitl.v 
«i,|. K to pn-vent aokyteais in the case of the jouita of the thumb 
(«•(■ p. ')''). 

("I Iniunf In Tdiiliois. This is fullv .•onsi'l.Tc.l nt p. W. 

{!*) To SHBi up the chief points: I'riinarv amputations. . sp.-cially 
what w«v he eaSwi fimnal operations, a**" only to be made use of un.i. r 
the verv ranut <firew»rtanre« ; any swueoii who mak.'s us.- ol th.'in 
will almost alwavs fiwi that he has o%-eT8t*ppe<l what was ab.solutely 
iHM-lfiil I'll.' i>iiit sh.Mil.l I).' tli..f.)Utfhlv clean8«'d (with the aid of an 
iiiia'.sth.'ti. ) by lu- aiisof turpentine an.l soap, with a sterilise*! nail-bruah 
and loti«»n. tW 8«»htti«»iw. it neeesswr. bmg mied continuously in an 

tinn-batfa. , i • i • , 

A won! of warntng niav not be out of place her.'. In hib desire t.. 
obtain as.'psis the sur^'tm should remember iiossible effects of over- 
si iititatiiiL' chemicals, mrh as fornialiii. oarlM)lic acid. &c. The 
Mt.ihty ol th.' soft parts is inii. li iowicl. an.l in tin' '"lsc of the lingers, 
th.'V ar.'. on thr.'.' thin and -asily coinprehsfd n<iain.sf chisely 

a.ijac.'Ut bones. The hopflesslv .lamai;.'.! solt parts shonhl be triinin.'.l 
an.l drainage provid.-.l. it is onl. by frreat care here that the surp'on 
is justified in submittinn his pati.'iit. during the attempt to save a 
inannled part, to tli.' danger of infection, gangrene, tetanus. &v. U 
th. re is unv .'iibt as to the eompleteneM of the cleamiBg. the part 
^hoii!<l U- k.|.t in an arm Lafh with « ik aseptic lotion constant ly 
i. iiewe.l. Hnr it is always a.lvisabl.' \ < . ' vv.)Uiid sweet and safe 
under a l...ia( ii' aei.l l.>in.'!itati..i in. I ^ ■ - as so.)!' as p.^sMbh- If 
any part must 1..- amputut.'.l. a isap .n ! mi or ten.l' ii th;.; inav he 
usi'fui i." tn l)P tmnsterr.-.l to the jiarts that are hein^ -^v .l. S.> t..i>. 
later <m it smfa..' is left, which bv cicirtrisiHU »J«wl\ will lead t.> OI if 'I'li'lons expos...! ha\.' tibrillateti and died, an attempt 
must be ni;!.!.' In . n I 'li.- o • 'li.i tak- !■ by <.r fr«»Hi a «listaiK'e, 
an.l replae.' ili.> .>th.r i>v Usianee-utur.'s (.^(r p. J-'mm.hir} 

. hiufrl. Mitrrb 4. 


o|MTatii)ns will mIsd iiicliul.- rcmoviil of any painful stumps, espprially 
those which iiiu-ilfif with th«' approximatioii of the thumb to another 

Fig. ift ail excfllent instance of what may l)e fflet-ted hy consi-i va- 
tivc surgery of the han«l. It represents the remains of a hantl. consi.stuig 

of the thumb, stunip of the 
index, and of the little finger, 
an<l also shows of how much 
ttexion tlie sfiortened index is 
still lapaljli'.' 

Value of Pedunculated 
Flaps in Injuries of the Hand. 
This method, which we owe 
to Dr. Fenger. is describeil 
in a lucid article by Dr. 
Schroeder. of Chicago. It is 
pointed out that Tliierseh's 
mi'tliod does not give either 
the elasticity or resistance 
which are especially needed in 
the palm ; the resulting scar 
is also prone to break down. 
It may. however, be usefully 
emplo\ ed on the dorsum. 

Dr. Sehroeikr s iialicnl »Cf<l :«». tlii- ri^jlil liaml. .oiiliai l«<! iiitci a liM, 
»Mfn left untmitiil .-iii<-.- a liimi in infamy. Its fuiu tions wcir almo-^t i 1\ 
(Kit!. -4). Thr hand aTid liulit liip were miwf caii fiilly iircparcil for Iw" 'I i.\> 
oiMTations wen- >ix ill numl« r. 

AVr.-/ I>i,nntinn. Tlif cic atri. ial tissue was (lisscct.-il cIT ill.- |ialiii. mip rit 
lliiimli. This h ft a woiiml oxtciidiiii.' fnmi th<- niriio riit lai arjial juiiits to tlu- diutal 
i)h ilaiiK. - I Kit' L'.'>). Tlir (h forniit V of the thumb was eorrcctcd. \>w thi- new jioitltioil 
U- Mi.iiiu . M.d «illi dilliciillv. thf first tinner wan xtill Hexetl by the shortened 
ant, nor lit iii. rit of ;h. lirM interi)hahiiig«al joint, which was mptured m exUiidmn 
th. tinu-r Th.' hand «.is now plaeed upon the hip »nd ineBMwi made in the »hin 
as ^riiid< s. i hr iipi^ r tla|. «aH made wkU- enouKh to ewer the drniMh-<l si«ii e uliovf- 
the Krst r..» .rf dijtital furruwu. having an anterior and posterior }>««*eJe. the diistal 
(>«d ol *e thumb |iai»ing out tfcroiigh the inwterior pediele (Fig. 2«). The anterior 




l-'i... .'». 

Hai.!.isx,.,l ,\. I t.. ll t ..I I hi- ilium. Til. - lian.l wa-now ! ' ' d 111..I.1 I li'- ill. 

Jia«i-|-s s. i.,,i..l..i. .inil 111.1-1..11- 1 1, .ijil-.-il. th- iiii.l.ll. Ill'- 'li-'^il I'haiat.N ..I 

ivs i'ln.l.-. Th. haml wa> aKam ri'inovi .l and thi- [.o. U. ts niadi . on^- i< .i-^.-arli 
f»»(git. h .^ I t- all I. h II lit* betwxw the liaiprK far iMwiiihim M Md bKlw tHNMo- 
^iixAtioii of the liiiK" 

Tntn*. A met. Svrf. .hvxc. , V.A U. p. 1 90. 

coNSKBVATivK snu;K'n oi Tin: iianh 


t .1 Lin nf the wn-t Tlirtv all' srv. ial imiK>rtniU I'lT- 
...lutmn^ to U' taken in this .1. r. "•'•"; '> ,„,„.„t.,noott» ti«iue mu»t be tak. n. 

!• » x;:y iitu «nit. to the ^ th. ^. 


iriiNiiMi oil ilir |H ill! Ii^. 'I'Ik' I iltri't (if iIm- skill iif till- liiiiiil iiiiiNt Ih- iiiiih'nniiM^ 
for ;t\ li aKt ii i|iiiii Irr of iiii im li. -n ;>!* til allow iif nisv ii|i|<ri>\iiiiHtHiii. 

Sl<-ritf gituxi* wait |iliic<il ui i(h- liai-k <if ihc linml. hihI (rmixi- tlrninx iH'hiiMl tlH^ 

l-l.;. J7. 

liiiL'' r-. A l.iiL'i' iIm --inu' »ii~ pliiiril iivri iIm IkiihI .uiiI n l.iiiic iI \<\ ,iillir>j\(' »li:i;w. 

A |il l~li I r i-r « ,1^ II \l .1 1 1| pi nil. I Ml'lliluiU flillll ill' ^lii illlilcl III t jir Jlllll,! n fillliil'.ll 

fiilil. A' tlir 1 ml "t ilii'i- i|ii\> ,1 I r,i|i-i|ii<ii' w.i» d'lL' -'i) rill III 'III' ■iii'l lliu 

•• 111. Ok. 

ill' —111!;- . h.iiiiriil. I;.. II. .1 ill -iiliitiiiii H i- till -iiimfltnl »itlinc(»»i<' iixctl in tiMw 
(ti.^-nii/-. Till' Hi'iiiiil \\ .1- (Iri -si-f I i-\ ' I \ tliiMiii.iv. 

>. ..,«,/ I i/H I'l'ii,!!. Till-. iN ifiiiiii. li irii (111 l iitlitli il.iy. I (I ill ilividiiift tlx" 
iiiiii t' |M'tlii'li> t(i ulu n' till' tliuiiil) |initrudcil. I'urt of titi.s [irtlicii' waa tuillfd to ilx 


U.-,..w-.rfth.-hr..k.-.n-.«..l M... .f. . 1 ■ ,,„„.r.i.|.T "f t»M. IH-I.rior fl..,. 

o,.n.,.:,,. On ; '^^^^^ i„.„.| ..,..1 H.«.;r. TIh- 

z :!rl::l'';;:l.n'::.":M-:: > "••'^ 

,,,:,;::;i:r i;. .rW....M 
r,;;"i*S»S.*.:U;.t-;:ri."'' <■ " 

I « ceil tin' 

I'.'l 'Minrttl 

*""'l',"f/* th.tatl<m. thr f wri,(y .lay th.' t-ri'l.." 

"■"';;r!,:'";i:;;n': m..-..^..^ ^« 

nil . I 1- I.. I.ilv. 


to ihfir ns|H-. tix. 

riiig tim-r «livUl« <l. iii.ll ilif >"< I 


, , , '!:'; ;.,;.; ui. km. i..-.. .h.-...i«......ui ik.v..i .i...-..f .1.. ;w 

.1 ,„,,., ,,;..,. .v.mia Ik- |N«sa,U, aiul |.rim«ry un.».. a-.n-". ; , 

„i,l «r.a .■a...l.».rstat.-HthHtitwa..u.t,«»«^.- 
1 Lilt. Iiv fn>iiurllt am l>n>\<ii .liai.iaH. lli'- 'I' I i" mi ii r. 

I 1 Tl-. .•x.fiilni-wi <rf til.- hall. "1 v. rv iiui. li im ....n. ... H. ilIh IH. ".m. 


, ,v .n.ltli.' II. X... t. M.l..nsfr,,K .■N|...>..linll.' l'al.n- Asin«l.'lla|.«astak.-lifnm. 

L I . all . \ r....M ..t,sfa,-....y .-suit fol!..w.-il. In tl... las. . a.s... aft.T a . 
,?.„ , . ' . a v,.,x l,..,llv . >nsl..-.l l.«<l fail.-l. th- i ujl.-r. aa.l of th 

, V,., il «. . k.< III.' iK .li. l.' »a.s l. iiijlli.'.i.'<l. I'lit low <l<>«ii. aial ill.' Hap l".ii«'<l "1> ""i 
ulii( Il ;!if> <'<'"l<! im-^*-*!- 



The question will ■omrtinif* arise as to the utIviHahility of attc-inptiiiK 
to rpunitc sov. ird portions of thumb or Viimvn. Many such Bum'««ful 
(u.s.'s hav.. (HTurr. (l. and the Hurjjeon may well imike the attemnt. when 
the parts are cieaidv severed, through a phalanx, especially the diatal- 
one. and when the patient is y«.un^- and healthy; when the cut ha« 
tMaied throujrh a joint, not throujfh a phalaii.v the "utl(M)k is far less 
promising. The followin}; are instances of the palt^ .severed : 

The tirnt, ■« i..n.l. aii.l third Hagt rH cut ..IT u diuKoiial liw UyinniiiB in th.- 
ini.l.lle phalanx of th. i.xlex Hngi f UH.1 eliding in the Lwt phalanx of the thml finger 
,„ar the r.M.t .,f the Ma.l. The |»rt- ii»<l U-.-I1 lying in the snow for «.im- time ..ii.l 
were kept for two or tU,< . t,„iirs U-fore Is ing apph.-d. In oth»-r .■•»«- the ,Nirt has 
Uvn wvere<l longituthiialU . .oiitaining in it a |M.rlion of Ikmip split oH. I !»• time 
between the iiuiwy and the treutinent has varinl fn.iii twenty miiml. s to three or 
tour boon, rad the ■even-<l i«rt has b»en pickr«l out of saw.liiHt. Lroiighi ni. m 
diHy paper, whibi in a third the patii-nt was mnt Iwck to Knd it in the tiekl in 
whi'-h be had been reaping. 

When there is the least shre.l ..f soft parl.> left lioldin-; on tin- 
severed bit. even a bad compound fracture of the lin>.'er with severe 
laceration of the soft parts may be .saved. , . , , , . 

The age and condition of the patient, the time whi< li has elapsed 
since the iiiiur\-. the part affected, i.e. whether the inde.x fiiifjer or the 
tliiimb. all be consid.Ted. .\nd. in any ca8«", the patient should 
be warned that, though the attempt may succeed, the parts unite, and 
sensation be restored, the result may be a sfilT and. thiTefore. com- 
paratively useless member; indeed, on this account, amputation may 
eventually be reijuired. , , , , f n 

If it be decided to nuike the attempt, the part should be carelully 
cl.'ansed with map and water, antiseptics being used with caution ; 
it is then united exactlv with a few salinon-gut or horsehair sutures, 
enveloped m a.septic wool, and kept in sUu with carefully adjustwl 
splint.s of jierforated zinc. The dreflsinga should not be disturbed for 
at least three days if possible. 


This cc'nj»enital deformity is sulhciently common and important to 
reqiure a brief notice. The condition is usually symmetrical, and there 
niav lie o ie or several additi«mal dibits. The chief point of importj^iuv. 
from a practical point of view, is the nwKle of junction of the siiper- 
mm.erarv dibits. This, consisting of two or three phalanges, may be 
joined bv mere fibrous tissue ; in other cases there may be a complete 
Hrticulati(.n between it an<l the side of an adjacent metacari)al bone, 
or the carpus, a metacarpal bone beinjr usually present, in addition to 
the phalanges, in the latter case. La.stly. the alli-d condition of 
supernumerary phalanx may be present in lases where the ternniiiil 
phalanx of a thumb or finger is bifid. 

Treatment, This consists of amputotion. as early a.s jKwsible. with 
strict asej f ie precautions, so as to secure primary union and a perfect 
HUT in a j ilt where a deformitv is so noticeable, and also to prevent 
the risks of infection when a joint is opened. In each casi- the finger 
is removed by an elliptical iiu ision. the flaps l.eiii" ( lit so iis to meet 
exactly ; where the union is fibrous, this is all that is leiiuiied. Hut 


and uniform. ,,,.f,„.,„i,v ,„av b.- produced. When the 
u SitrS'lp;;:'::^ li r.„nr«l i„ c«rryi»« 

"''\T.:^ZT. bifid ,.hala.,x tin. /""SrVuirr^Juht 
: 1 'I s u ton ThaTi-ortion of the phalanx which w the larg.'H . 

wh . n ™t tl^ ^it ...ft from being bkLight into .h. stn..,l. 

K, . Vh MH.n as tho wound 18 heale.l. .Mn-ftil niov.- 

'"iV'.n.-' tlu- ,l,..l.u,x into the straight U»e »u«t be 
nrSJid eJerv f.-w davs. a nu tal splint worn a <h.I ar round the 
K with a lateral prolon>;ation .onnn^ up alon^- th- ntW.te.l linger 

nimf oJ he «dJ away' from that to which tfu- »>'-l-'>^ l'''-;-, 
t i" longation admitting ..f bi-ing bent outwards to ans n.edf. 

!t..n this ineuns the phalanx, which i- at fault, can be 

strilight. But Frneverina <liily treatn^nt for four or «x mo.»th« wtU 
be required. 

wmiD mant (if RDAORum) 

(Figa. •>'• 

Th se should always be remedied in early childh.KKl ; Ij jj 
...u. lie I the lingers inkv be useful, but the annoyat»ce of the d'-f""'"^. 
. serious. ^ The su, .eon should not yield to P"««" «» 
operate in early iufan. v. Simple .livision of the web-a trifling 
Ji m is out of the M"«'«ti"" the .nev.ta .le rc-urren.-e 

theXformity. On the other hand, especiallv if extensive d.s«ec ..m.s 
e maie in raiding flaps, the loss of blood will be 7''-' j™ ' - ^ 
without risk both as to the vitahty of the flaps and of the infan its. It^ 
N operation should bo undertaken before the child is at least hree 
;-,Mrs in .•as..s where tlie union is very cUwe. it is preferable U. 
wait till the age of four. Where sev. ial fingers are united, quite a 
mtmth should elap* between the operations on the hwt »nd second 

'^'xhe treatment will deiHMul upon th.- condition aii.l . xtmt ..f .be 
In th.> slifiht.T ca«'s there is merely an increast- for 
.listan. of tl... normal web : there is then an objectionable . e{..nuity 
rather than anv a. tual .lisabilitv. In tl... more senous '^f"^ ^he ^..^^^^ 
may be joined d..wn to the tenn.nal phalanx. The web may then be 
lax and free (Pig. ..r dose an.l tbi. k (Fn^. or tw.. f.ngem nuiy be 
more or less comph'telv iointnl by bony union of phalaiijz. s 

(1) The simpler methods, yiz. w.-arin;; a pi.>ce ..f tln. k silver win- 
..r lin.. .Irainag.- tiibii.}; thn.ujrli a Imle made through the base of the 
web where the cleft shoul.l b.->jin {" ear-rmg iH'rforation). may first 

Fill. 3<>. Agm-w's oiMTutii'ii for wcIiIh iI lirifrc is. 'I'll 
flap is UorMiil, large, ami singli-. (K<'<-n ami Whiti- 
JmerkttH Texl-liHii uf Surgt ry.) 


be tried. The tubing, whicii has the advantage of interfering less u ith 
the movements of the hand, niay be attachetl to a band round the wnct ; 
the wire may be twistetl in a loop round an adjacent finger. 

When the perforation 
^\ is soniiiliy i-ieatrised — 
' /.('. ill about tlirec or 
four weeks the web 
should be slit up, each 
half split, dissected up 
for a little way, and the 
edges of the two flaps 
thus formed united with 
a few points of sterilised 
Horsehair. The greatest 
care must be taken to 
secure primary union, for 
(itherwise granulation and 
cicatrisation will inevit- 
ably lead to contraction 
and displacement of the 
finger. The fingers siimild be ke])t apart by a layer of gauze tlirough- 
out the healing. This method has the disadvantage of being tedious, 
and the fonnation of epidermis round the foreign body is liable to be 
incomplete. . 

(2) If the above fail, one of the following plastic operations should 

be made use of : , , • i 

Agnew's or Nortin's ' (Figs, .io ami Tliese can only be carried 
ouc in cases where the web is ample. In Xorton s operation (Fig. -il). 
small triangular flaps are raised on the dorsal and palmar aspects of 
the base of the web which is cut then through and the flaps very care- 
fully stitched together without tension. 
The object is to ensure rapid union in the 
upper end of the cleft, and thus no re- 
development of tiie v.eb. Agnew's opera- 
tion iMupioys a siiiglt! larger Hap (Fig. :5(l) 
raised' from the dorsum. The flap should 
be thick enough to avoid risk of shHigli- 
ing. and soriewhat narrow to avoid 
biiigiiig. To i)reveiit tension it should be 
sutlicieiitlv long, its base being at tiie level 
of the metacarpo-piialangeal joints, and itv 
ape.x. which should l)e rounded, ahnosi 
reaching to the base of the second i)iia- 
langes. The apex is sutured to tiu' palmar 
edge of the cleft, and its sides to the skin 
at the edge of the wound. Any re- 
dundant tis.sue between the knuckles 
that prevents their coming together 
should be cut away. The remaining web 
is then split and treated as above 
described. The line of the natural web should be carefully preserved. 

Vlr.. .'tl, 

Niirtiiii s (>|H'iiiliiiii fill- 
liiiKi'is. Tlif Hiips urci 
<imall ami <l<HiMc. 

t On the Continent this operation gi«'» by the nan»e t>f Morel-Lavallve. 


Didot'i (Fig. 32). This operation was introduce.! for th.>s.> (iis.'s 
in which the web is very narrow. Two narrow lonj,'itu(Hnai llaiw are 
dissected up as thick as possible fr.)iii th.' palinai ami .{..rsal aspects 
of the affected fin<;ers by two incisions, one al.nig the mi.i.ll,. Iiri.> „f tl„". 
.Inrsiiin .)f one finger an.l another along the mid-line of the j)aln,ar 
siufa.c .)f the .)tli.'r, from a point opptwite to the extremity of the web 
to th.' knu. kle By sli.)rt transverse incisions at each end of the vertical 
.)n.>s (Fig. :i2), the two flaps are marked out. These are most car.-fiillv 
rais. .l {see below), and each flap is then folded r.)und to cover the raw 
surface of the finger to which it i.s attached, and .s.-eured with a few 
interrupted sutures of fine silkw.)rm-gut or Imr.sehair. 

Di.h.fs. like many French operati..ns. is m.wt ing.-nious and on 
pap-T. It Ooks an excellent one. Int. in practice, the following obiec- 
tiiins will present themselves: (I) It 
is a severe operation, especially in 
little children. (2) It is not easy to 
raise satisfactory flaps in parts so .small 
and with skin so little developed. Thus, 
if the flaps are too thick it is .-asv to 
injure the .-xteiLsor tendons or digital 
lii't v.'s or ves.sels ; on the other hand, if 
the flaps ar.' too thin they slough, and 
infection then readily occurs. (3) The 
flaps are nearly always insufficient to 
cover the denuded surfaces unless thev 
are submitted to such tension as may 
lead to sloughing. Thus in part the niiKstlu^al by granulation, which 
Miiiv lead to harmful contracting scars, 
"1 li.\- the aid of skin-grafting, which is 
liable to be rendered futile by the rest- 
les.snes8 of the patient. (4) Consider 
able difficulty will be met with in fitting 
n.'atly the quadrangular edges of the 
ll!'mril\veb ^ satisfactorily to re-establish the 

I'or the above reasons the method of operating by a trian.-ular Han 

r. those rare cases where the union is bony, the choice lies between 
l.aung things as they are or (6) removing the bone ..f of the 
in t,. 1 after this adequately by tw.. rertangnlar flaps 
-..sal and Hmar; Separation of the fingers is not .1 
t h a'n !;;;r'';'^'''Y "^'^---'''.'''K «'^P« ever the raw surfa " 
iiMg.'is. Winch will probablv re<(uire amputation. 

After all ..porations on webbe.l fingers, especially the one introduced 
. . . t. th..... ,s more or less tendency for the fingers to b.-com,. stiHIv 
V.I o. <..xt..n.led. according as any excess of scar has formed oa the or dorsal surface. Thus it is v..ry . ..mmon for the finger which 

' Liiiiti l, June i'J. Isui. 



Fiii. 'M. Didot'.s ii|N'ratii»ii 
wpbhe.1 finders. (Rwvos.) 


has the .Icsal flap, a.ul in wlmli the cicatrix lies along the pahnar 
rarface. to become Hexe.l. 'I'his tendency n.ust he bv ^r^vv^ 
use of a splint, one «innlar to that at p. ^.» "'"'f l' "^ 
to the doril or palmar surface of the hn>ier as At tM^< t 
must be worn laV and night, and then removed or varv m.u . » is 
in the dav to a.bnit of active and passive movements hem- assi.luou.'^lv 
practised: It will require to be worn at night for many months In a 
few cases of this deformity a pedunculated Hap taken from the dorsum 
will provide the most extensive and mobile skin m the position of the 


(Figs. 33, 34) 

Dn.Mivtien s contraction of the palmar fascia is usually met with 
in middle-aged men. Though it often appears to be due to continued 
slight irritation or injurv, such, for example, as is caused by the frequent 
use of some tool or instrument, it is undoubtedly in inanv cases associated 
^vitll a tendency to gout. The palmar fascia is tr.angu ar .n shape : the 
apex is attached to the anterior annular ligament, while below it ttr- 
„ inatcs m four processes to the four inner fingers Each d process 
consists of a central portion which joins the theca and tw lateral 
processes which are attached to the skin of the web the capsul, of the 
metacarpo-phalangeal joint, and the sule of the first phalanx Thi 
contraction takes place especially in the pr..cesses going to tl. two 
inner fingers. Commencing about the transverse palmar creases it 
steadilv and pix.gressively cripples the hand by drawing «lown the 
Hngers. causing flexion, first at the metacarpo-phalangeal and later 
at the first interphalangeal joints (Fig. 

Operation. This mav be either subcutaneous, by multiple punctures, 
or open, the latter being effected either by multiple transverse cuts 
through an open longitudinal incision or by excision ot the contracte.1 

'"The SubcutaneouB Method. The best is Adams' operation in which 
the contracted bands are divided by multiple punctures from the surface 
downwards The skin must first be carefully prepared aiid cleansed. 
If thought desirable, local aiueslliesia may be .>mployed. Finding some 
spot w£ere adhesion of the skin to the fascia has n,.t ^•et taken place, 
the surgeon, avoiding the site of the vessels, passes a fine sma 1 t."n<itom> 
knife between the skin and fascia, and divides the band from above 
downwards, taking care not to dip the point too freely If too iiiucfi 
straightening is attempte.i at once, the punctures ^x^\\ gape widely 
and readilv tear, especiallv where the skin an.l fasca are adherent. 
In cases of contraction of two fingers, a ninnber of punctures- oj- hve 
to nine-may be required. It is usually easy, by operatmg on the 
palmar bands, to rectify the contraction at the metaiarpo-phalangea 
ioint. -^he straightening of the contraction between the first and 
iecond phalanges^s much more difficult. The digital proh)ngation8 
of the fascia may be divided by punctures m the web between the 
fingers, extreme care being taken to avoid the digital vessels n«v^ by 
not^eiressing the point, and by keeping to the middle fine. But when 
the su^n fiids some difficulty in correcting this contraction thoroughly, 



hf will act most wisely by correcting the reniaiiiiiig contraction gradually 
i.v tlu" use of Ailnnis" finger-splint with rack-and-pinion movements 
,,|,|i.isit(' tlie nietacarpo -phalangeal and interphalangeal joints.' 

Till' splints, which should be constructetl of metal to combine liglit- 
-s with rigidity, should accurately lit the pahn. and the length and 
1,1. M(ltli of each linger. They are secured by broad strips of soft leather. 
At intervals during the day the splint should be removed, and the hands 
ucll soaked in hot water, .scrubbed in this with a nail-brush, and the 
|iiitient assiduously practise placing the aft'ected finger-tips on a table, 
iitid then making pressure on the dorsal surface of the fingers with those 
of the other hand.* The skin should be most carefully cleansed, and 


aseptic dressing a))plied for three or four davs, when the jmnctures 
uill lie practically healed. The splint should be worn day and night at 
tirst. carefully padded at all pressure points. Some weeks will be 
re(|iiired to correct the interphalangeal contraction, and in advanced 
I ,iscs relapses can only be prevented by the persevering use of the 
>l)liiii. In any occupation which entails much grasping, g' lves padded 
111! I lie ]i:i]niar surface should be worn. If the surgeon atteni|>ts to 
>tniii;Iiten completely an advanced of phalangeal as well as of iiieta- 
1 111 |iri-plialangeal contraction, he runs the risk (I) of dividing a digital 
iiiiAc. which may lead to most intolerable pain; (2) of damaging the 
I' liiliiiis. for these batids are often in close relation with the theca ; and 
I "t injuring the vessels and thus producing slight gangrene of the 

' ntliir splints will 1>. foiinil tiu'iircd hy .Mr. Ailiims (/.d/ir. I Hi)), vol. ii. p. 1(16). If the 
-kill his iH'fii iniii'li dtiaini'il or intorfirtKl with, the strnialiti-ninj! slimilil ho defenwl 


The threefold association of the palmar fascia with the thcca, the 
skin of the web. an ! the superficial transverse ligament is, as the result 

of the (lisfusc. reiultTcd more iiitiinutt' than fvcr. 

To ffuanl agninst a rt' the pationt slioulil, rffiulaily and inethodi- 
cally. practi-t' active and passive movements of the joints, wear the 
splint at night for a (•onsideral)le time, and If any persistent or recnrrent 
bands threaten to he trouhh'some. treat tliese hy rnhbinj; in oleate of 
inercurv ointment. Should the patient be the subject of fiowt or atldicted 
to alcohol he should be warned and treated accordinfjly. Fifjs. 33 and 
.'U' represent a rifjlit hand crippled Dupnytren's contraction bi-fore 
and live years after operation. The iii.iii was a ])afaent of J)r. J. K. H. 
l{urr<>ui;lis. of Lee. and was operate<l on in 1MS.'5. the contraction 
ol tlie mctacarpo-plialan<;eai joints beini; straightened at once after 
iiuiiientiis jnnictnre.s made in the manner <le.scribed above, while that 
at the interphalangeal joints was remedied chiefly by the presevering 
use of Adams' splint already described. In 1 890 the fingers could be 
completely extended, were perfectly mobile, and free from the slightest 
tendency to contraction. It will be .seen from Fig. IV.Ui that some 
thiekeiiitig. puckering, and corrugation of the palmar skin and fascia 
SI ill persists, hut this had now no j)ower of ))roilucing contraction, the 
I>atient. a relieving officer, being able to write. Ac. without any hin- 
drance whatever. But to show the importance of persevering in the after- 
treatment mentioned above, when, after another four years, the patient 
was again seen in J894, there was some recurrence of the flexion of the 
interphalangeal joints. The above advice, which had been insisted upon, 
had hi'eti entirely neglected. And this is very often the case, owing 
to ))atients thinking that the operation, of itself, will accomplish every- 
thing, and that no re.spcmsihility in the after-treatment rests with them. 

Operation by Multiple Transvene Cuts through an Open Longitudinal 
Incision. This method has heen advocated by Goyrand, Kocher. and 
in this country by Mr. Hardie. of Manchester, and Mr. Keetl -y. It has 
been recommended on the ground that mere subcutaneous division of 
the contraeteil fascia cannot be sufHcient if the thickened, puckered, 
hardmed skin is left alone, and also that iiitiniiite adhesion of the altered 
skin to the fascia is so general that it is dillicnlt. if not nnpo.ssible. to get 
the knife bi'tween the two at a sulHcient immber of .spots for adeipiate 
.straightenii',, by the subcutaneous method. Keetl y, who advocates 
this operation, thus describes the ,stf p.s. " The limb having been elevated 
and an Esmarch's bandage applied, the hand and forearm, carefully 
.sterilised, are held extended and siipinated on a sterili.sed towel on a 

mall table beside the operating tal'li". with the (ingers as nnich exteiide.l 
and separated as jKi.ssiMe. A longitudinal inei.sion is made through 
the skill and into the contracted fascia. If the finger is much contracted, 
this indsioii can only be completed by degrees, as the di\'ision of the 
bajids gradually permits the unfolding of the fingers. The extent and 
degree of the contracted fascia are now easily seen, and it should bi> 
divided ly ihkI < ()m|ileti'ly in nutny places until all resistance 
is removed, and nothing hot sliorti'iiiiig of the ligaments and structures 
.iround the joints ivniains. This shoiihl he left to be overcome by after- 

reatment. Hen' and there the skin it.self may have to he freed hy a 

• The nstrrisks in I'ii;. M -iiots wh. re the IciKitniuv knife niijtlit be iiitimlueed 

in contraption ..( the jalnmr fav o„i„^, |„ (1,,. ring UnRcr. The contrwt«l bAUtl 

tIniH i!M>l«fe<l by the piini tiin's Krinliiallv atrii|ihli>s. 


loin li of fhf knife. 'I'lit' skin incision is clciscd liv silkwnriii-^iit mitiims 
plaml closi- to the tnljies of the wcmjihI. If the ahov.- (lireclions ,iiv 
xfrictly followed, merely a linear cifatrix will remain, siuh us lontiasts 
lavoiirably with what has lic. n n poitcd jii* the ultinwte state of thinas 

.iftcr cxrision of the eontracti'd fascia." 

Excision of tbe Contracted Bands of Fascia. (<i ) lli) l{, , i,i,i.,,(liir FUnm. 
The .skill hnvinj; been, for two tiays at softcnctl by tin- frequent 
use of soft .soap and hot water anil the iniiiictioii of laniiline. and rare- 
tiiliy .steriiisetl, u loiifritudinal ineision is made over the eontracted f>an<l 
from its upiHT to it.s lower limit. an<l then small transverse incisions 
are made at eaeh end of thi.s, .so that two sinall rectarii:iiiar Haps niav 
l.e dissected np. A twofold difficiiitv at once presents it.self : (I,,. 
A<\\\ is usually so aillierent in places that the .satisfactory niakiii}.' of t liese 
il.ips is hy no means easy, a difliculty much increased bv the tle.xed 
position of the linger. A hard band of horny adherent skin mav Im- 
h iiioved by a narrow elliptical inci.sion. The" coiitractetl fasc-ia. when 
exposed. IS di.ssected out. and the flaps united with .silkworm u'lH <>r 
horsehair. The second difficulty is now met with owini; to the con 
tnictioii and ailhesiim of the .skin which has to be united. " W here union 
I- iiM|)o.ssibie. skiii-;.'raftiiii; ' oujjht to be eiiijiloyed : anv surface left 
lo ;:niiiii!ate means more or less recurrence of the troidile. 

I'h) H>i „ V-shdiial iiirlsi.m fFij;. The base of the \ is opiM,»it.. 

a little above, and oveilappinf? the root of the atJected linp-r ; the 
pe.\ IS situated in a line with the centre of the same finder, in the {)alni 
about on a level with the transverse Two diveif;in^' iii< isions 
join these points, and are carried down tliroujrh tli.- skin jriid fa.scia. 
Tile latter may be divided conii)letelv or removed entirely when the 
liii-er can be .straiirlitened. This l.-aves a ^Mpiiij; triangular wound in 
t ie palm with Its ape.K upwards. Tli.'oreti.allv this should be united 
hv careful stitching' in tli.' form of a Y. Hut the contracted state of 
the .skin aliiio.'t always prevents accurate .stitchin<f. and h-ads to .some 
-.'apinj; of the wound, and a raw surface which mav re.piiiv I'laftiii" 
For the severest cases Sir W. Wat.son Cheviie an.l Mr, Muruhaid - le- 

• oiiniieiida combination of the subcutaneous method aii<l tlie\ -sliaped 
iiK ision. •■ in very advanced cases, where the tinjrers are ti-ihtlv bound 
■'ouii to th.' palm, removal of the fascia by dis.section cannot be per- 
ioi iiied. becaus." it is impossible, on account of the contraction of the 
liii«.-rs. to fret proper access to the palm so as to make the rerniisite 
iiui.sions. Under these circumstances the best treatment is to divi.le i|,e 
las,'ia m the first instance, and toget the finrrer as .strai^'ht as possible |,v 
this means. .\s a rule, however, division of the fascia will not allow the 
(iiiifr to come ((iiite straijriit. because the skin it.self is contracted and 
'ii'ielnre the r<-sult is incomplete. The operation bv the V-shaped 
I'M isi,,ii may be very usefully combined with tenotcmiv'so as to compel 
'l e stiaifrhteniiifr of the fiiijrers. The two operations" shouhl, h«)wever 

I 'I'lne at diiterent times. The result of the tenotomy is to endanger 

' Nl<iri j.'nifliiitf ha:, Lmi s„iM..ttliat li-litly irrnmmemle.l in tl„ M- . t. cMerl.nM 

• "."P .^te the h.-uli,,,. The f.,i:.nvi„„ cautieiKS mav l.e . ,n|.h:,>ised • ,1 V " 
■■■ -..le,[ siirfacy n-ina.nin- after an ,.iu-ii ,.,„.rati.,M fur ,■,;„! rart,.,l palmar fa>,. a i, f 

■ I m nianiml labour, the gmfu may not afford » pernmno.t protcaicn. |'la,t t- 
. on, aro out of ,iuc»tion m tj.e«. patient«. »K,th from a l.Kal an.l a more ^-eneral 
' ^ Manual o}8»rgiealTrrutm:Ht.\o\. i, \i.m, 



tho vitalitv of the rfcin at vurioun ,..ints ; 1......... 

slou. hs n-,l-Hs t..o great a pn-s«...v h. .... 

f S i. t tin... ...UHt iK. all..w.>a to .-lai-s. 

very ran'ly 

tho vitahtv of ^Xta;;ZZ • . -i.l.t t.. U-n ........ it. - 


1, 1 




K,r T,.t»l .■.•m..v.,l ,.f >...ilt«rt"l («»■» ."■"•»"ily <«1<" 

„t ,„.Ki,r„ ,,„„.■,> ^ ;j.^'f ,1 |„ ,„ ,.„,.,„i„„„l 

:i;!,rK.,;i;:v;r"n:7;;;;;,;ir:, St.;:";;; " 

!*r.,^o,1 t„ rolnT>sos will b." (..iiipaiatively infreqiU'ut. 
"*t^Se-whrpEtl- n.ore rocUy adv-ocated methods must remem- 



Ihi tin- following iKHiit.s. viz. tin- ap- ami vitality <>f maiiv nf tluw 
|iatifntj<: tlu! iiwhI i)f tliorotifili stfrilisation of the skin not an easy 
iiMittor when the contraction of the fingera rt'iulerH acc<iw to ull the 
Im.IIowh and inoqnnlities difficult; the oozing and ponsible nmnl of a 
,i ,111 : till" fact that the piicki'icd .state of thi- skin always niak.-s accurate 
,-iit(liiii>i (litlicult. Icadinj.' to a raw suifacf and tin- iifcd of grafting, 
of till' ohjfctions to whit li iiii-iition has aln-ady In rii mail-, a nri'd 
which in iniicascd hy the tendency of the .sutures which it has heeii 
possible to insert to cut their way out owing to the necessiiry tension 
in places and the diniiniBhed vitality of the skin. Lastly, there is the 
swelling of the hand which may occur, especially in gouty patients, and 
which interferes greatly with the use of splints. 



III aililition ill l)li|iuytn'i)'s loiilim liuii. Ilii n- is a siiiiii'wiiat similar i iiiitn'iiitiil 
ill fniiiiity. occurring ehietly in firls. in wliii li one liii^i r. nsually llic little imr. is 
III A. il at'tlii' " ' i'ltc l>haliili>!ral jiiiiit : tliric may alsn ln> tli xion i.f the mm iiiuI iiiti r 
|.li,il.iiii;r,i' • 'ii- lirst plialaiiv is liypi r i xti iiili il on the mrtai ar|ial an 

ii,i|,iiilaiil M l)ii|iiiyticii's rontiiu lion. The cimilitinii may l>i- I'ilati ial. 

I ll, iiiIm ii> 'ie in a rontiaction of the central sli|> of the iirolniinatinn 

,,| I III' fa' I the'ia of tlic |ialiii iimi tin- liitenil Mli|Miire not atTectetl. 

I Im'I'c is ,, •ntcifcrcnie with the usefulnetw of the hiuiil. advice being 

Miimhf on i>.,,... . ' the ilcforniity. Palliative treatment can only be of avail in 
i iirly life, when the Hiiiall size of the partH renders it difficult to cnrrv- it out. If 
..jM i'ation Ik' undertitken, the o|>en niethiHl with multiple transverse im isions ran 
111- easily made use of as the Hkin in not iitTecteil, and the hand is mcilian. so that the 
ilii/ital vi ssris and nerves are not endangered. If the above lie insuOii iciit the 
lateral liLMiiients of the Hexed joint nnist lie divided, and tendon-lengtlieninn may lie 
iiii ilfiil : in the nnist l onlirnicd l asrs, where ankylosis is present, tiie ijiii stion of 
I'vrisioii or ainpniation will arise. 

Severe Contraction due to Injury. Here such Nte|is as tendon-lengthening 
I' '.>!•) combined with a plastic operation may ovcai)ioiuilly bo employe*! with 


Snap or Trigger Finger. In this rurious condition full extension, more 
laii ly tli xion. of one linger is prevented and can only Ih' attained with the help 
of tlic other haml. the linger U-ing now suddenly flexed f»r extended with a snap 
like the cloNing of a blade of a iHx;ket -knife. Some pain and tendenn-ss are usually 
i x|»i;rienced near the metacarpo-phakngeal articulation. The (mthology Is nn- 
iirtain. In some eases a thickened synovial fringe has Im-n iomnl, in others a 
small paiijilion is present, wliih- a large sesamoid lione is .sometimes tlie cause of the 
tiiuilile. The articular surfaces may show the changes eharaeteristic of osteo- 
iilliritis. The treatment is to explore and if possihlr to remove any caiisr whii h 
III I V 111' fimnd. 

Mallet Finger. In this deformity the terminal plialanx is sli^ilitly llexi d and 
. iiiiiiit lie i xteiiilcd. It is nsnally the result of an injury which has eitlii r stretelied 
! h' I \teiisiir aponeiirosis. or torn the central slip from its insertion. If a splint is not 
h , Infill a median lon«ituiliiial incision must he made, the extensor tendon is 
)'li iititicd and the piDxiinal end stitched to tiie |KTio.steuin. 


Those who are aware of the difficulties which may accompany 
\ploration here, and the nnsatisfactory results which sometimes follow 
n this step, will be faniiliar with the need of having tv^o skiagrams, 
iiie taken laterally and one untero-po.steiioriy. While on this sub- 
jt i t two hints may be given : one is tiiat the needle fragments may 
I'c soriietimes multiple iiere as in the foot, the other, that skiagraphy 
especially useful in doubtful cases, e.ij. where a patient evidently 
neurotic complains of a hand being numb, useless, or painful, when 

«, OPK.HATI..NS ON Till. . ITLl. K.XT..KM1TY 

. ..f til.' iiwhHp, nr when one 
there i« some d«mbt «m to th- I'X" ' .l. \Vitl. repn,! to the 

n lie frapinent h.» been ''y'-'''; . r r Ksnmr. l.V Im -s 

„,„.r«tion itself, the UHe /V '^' . X-ravs. . onsi.le.ahle 

.litJicultv may he expeneneiHl in t n ^ ' ,„j-,..h ..I the 

due to itH .m>lacement hv J'' \ \ U l.r«f the ^f.a« t. 

operation, or to the snmll " ^ ree Mn (.1«kk1 an |H«8iWe l.v 

tW wound Hhould therefore be •^7'\;; ' ,|„. i,„.iHi„.. U nuule 

Rentic «,>.Mipn?. the . "1 h- n the most .liHienlt ease« it 

exactly over the situation of t^;' »^^"^" . ■ ..x.inim.ti.m in the 

,„ay he desirable J "J^^;^'''^ : -lii. 1. is 

eourse of the ,.,.erat.on, •"'"""/""f J"^., ,1 ve, may, .t 

employed for extra. tm.- f'''^''"'"*'', " / ^.l^; . thi« ..ften fails as 

::^;s?br^iS!rxrr,s;S the . at .... 


metacarpal bone. . j „ removal 


of « n«..U- fnui, the l.ahn,wp ; , ;,f of the liim-rs that 

it «a8 clear from tli- sears ^""1 ''^ . "^^ " sl,..„ton .k-n.onHtrate.l tli- ,,...e 
i,«..,.tif r.'«.ilt Im.l n,.t a way l"- n ^^^ ^.j „f the tiftl. meturarpa l-me. 

a little alM.v.. ,1s has,- Tl, j"'"''' f , Ju "'-■.■-n' fniK-'M -it '">' '• 

,::;;:':';ri..;".S.":::iu:r Mill, uj; .ro» vatieat«in»bK, her 

, 1 1 f i,.,t uhen the needle is deeply placed, 

It mu8t always be reP .'''^''■'■'1 ? „ . , .J such as a nerye. tendon, 
there is a danger that. son.e 1"^- -;>^^t^- ^ 'mnoyal. Suppuru- 
or artery, may be injured in I*' p„r theso reasons, 

tion. too. will be attended «-h,us J^^^^^^^^^^ 

..,,.,..ially in <'l'l<'rfy.Ptrt „1 C^dvii wait and see whether 

•ill aiiasthetic undesirable, it may ue auvio»u>'. 

;r p;;ince of the needle causes any severe symptoms. 


,,„., .aerialarches in the I:;;;; iiAl^i 

,1,.. .s,>,,.ili. ial palnmr arch, foimul <hutl> > > ' 

Iv a laaaLh fiom \he radial, --^^..^^ 'ii;^'', ! V^' - -f'-^- 
areh forin.-.l l.y the ra.lial and con.i Ut,. > ,tcnor 
The anterior and }K,Htenor '^fy'il-;^''^^^'^ ^^'^--^ -^^^'^ occa«ionallv 
bwnchcs of the radial and tjlnar. < ."i . , ,l.. n usually joinH the 8u,M.rt,eul 
enlarged at the .'xpense of the o 1" • ^ pfy'of the han.l. Th.> 
palnwr arch and tak..s an '"n-or j" ^ h h supcTjic ial to 
iuiHTficial arch ,s s, uate< „,.,,.e ; i, can he .narked out 

thl flexor tendons an.l th- and then curving .low,. 

^^"C:!::^;!:-^Th:rt;;rvary.aceordi^^u^j- - 

wiU also depend upon the septic or a-eptio natuw of tde wouna. 



A. Early Caiei. iilci'liiiK ' m.iy iir mI\.:i\s if iMimt niiv . umiimIIiiI iiy 

|.ir"Uiv or li\ ill'' iiM' of n toiirniuiii't. 'I'lii- wound will "firii !«• •.mull, m' ••vi ii 
I iiK ri' |iiiiii'tiiri'. The nuMt dmintltlf nict^MNl i», itfti-r lh<' iikiii Imm lM<fn i-kmiiMtl 
. ili<iri>uK)>l,y ii* iHiMtiblf. to open up th« wniinil umi Mi-uri' lioth emlit of tht; injumi 
,,>M-\. ThM w fiur prrfi>i'itl>lc to liRatore a( tht^ brachial, or of the ubiar or nHiinI 
.iitcricM. fur the lilre<)ing nuty i-om<* from a Minall branch Huuh an thi> NiitM-rtlrinliH 
vitki' itml not from <mi> oi tht- juilniMr im-UcM. Ariutlicr im thiMl im Ky lh<- 
tion of n graiiuatMl fom|>n<Hii whicli may )>•■ li'ii<l if tin- witiinii In- a hiiiuII |>iiiii liirf 
,iihI IIm' l>t(«(ling not m'Vcn-. Tlir linirhial luuiiiu Im i ii ('iiiitriilli il liy a t<iiiiiiii|iift 
jini tho wmnitl elmmH-d. a <i)m|ins« rciii^i-<tiiiji of >icrlli.Hc<l jtaii/.i' or liiit. nil in 
i.h ( CH imTfajtiiitf ill si/.f from a tlirti'iK iiiiy liit to half a i rown i-* |iic |),iii il. Iol'i lln r 
uilli Ktrappili)!. Ntfi'ilitii'd pails anil liaiidat'rs. 'i'lii' liiij.'iis an' ipm iMiidi'jid. 
tin- 1 iiiii|>lf.--s is plarrci in |M)silion, i o\ criil liy llii' shiilisid pads alid«iriiiid l<\ 
1,111 till liaiidacini;. If tin- alioM- piri aiilioii \><- omil ii-d. so iiiiii li and so p.iinliil 

ma of till- liiiU' i's "ill laki- place jis to iiii vitalily lii ri ssitatf rally n iiioxal of 
ihr l oii pu ss ami inolialilr ii c iniiiii f of thi" ha'morrhiij{,'. Thr iirm sliimid In- 
ki pi at li st oti u Mpliiit. or iH'ttiT still, tht' I'lltow Hhoiilit In- fully llrxi'tl aiitl thi'iirm 
liHM'ly ImmuiiI to tho nuIo. The intk-nt, if mttleM. nlKiuki at timt bt- kept uiHlt-r tht- 
mltiu'iiit- of morfitiia. Thu compnuM MhouM not be diHtttrlN-tl ftir thrt-i< or four tlityM. 

K. Lkttf OhM> If pn-HHiiru hitH Ix-t-n trit-<l but Iihh not In't-n succi-HNfiil. ihtt 
uiiiiikI. owing to the ililfii'ulty in n-mli-rinK tht- xkhi of the pilm ascptii'. is likfly to 
,• Itifn lril : till- hand will tlit-n Ik- ird, lirawny. |uiiiiful. ami siippiiialiiiL'. If 

iiioiihaiti' slill rontinili-s aft<-r tlif triisioii lias iMt ii rilii'vcil liy can fiilly mailr 

i>ioii> it will Ih' lii'st to til' till' lirai'liial artrry ikt uneu in tlu- luitltllc of tlii' arm 
|i. 171 1 ratliiT than to liuaiiiii' tlii- radial and ulnar in thi< h>wcr third of tlH> fon-- 
ariii (pp. 1-7, l:i I), and fur tlu-xf rcitHoim : 

(I) LiK'tturvof the brachial Will bo performod through ht-nlthy iiihI uuinHiiiiiiil 

ij) \\ liili' till' aiiastoiiiosrs round tin- clhcw an- so fnc and .so iclialili' as to 
piiM iil any risk of nangrcni' afti-r ligaliiri' of tlic main vrsscl. lij^atiiri' of tlir r.idial 
,iiid ulnar is icndrri-d unut-rtain owing t«> (a) tiM' »m»«ttnin**t-»t l»t-twifii tin- two 
pilniar archi s ; (/>) tlu- tumstonioiw-M betwvi-n thuno and the vuriKil nn-ht-.s ; (c) tli<- 
IiIihmI brought by the conim ncrvi mt-tliani artery, which will not Ik- Htop|Htl by 
lijiaturc of tho radial and ulnar ; (</) the fact that if inflammation haM M-t In, 
dilatation of the arlcrii-s will havi- taki-n niace. 

After early ligatiiri' of tlic injured vessel the wound may bt- infi-clfil. and st'iondary 
li.ciiiorrhage occur. L'nder these uircumstanoos an attempt again to m-eurt- the 
lilceding vcsncI in aitu is likely to fail. Lir^turo of the bntchial win tlH-n be indicatctl. 


Till- rarity of this disease in arteries so small in fi/.i- as of llir fon ann ,ind 
ImiihI is well' known. Ancuiysm when pnaieut in the puliii is usually tlu- it-suli uf 
iiiimy. or much more rarely it is embolio in nature and coH-xists with serious disease 

.if till- heart. 

Ill a third class of l the am iirysiii is an instaiue of localised subacute end 
III' litis deformans,- and arises without any known eaiisi-. Hero otiier arteries 
..7. the cciibial are very pioliably also a'tiected. The inner part of the 8U|ier- 
!m iai (laliiiar arch is that chielly atfected. 

OjHriiiiiin. If other treatmeat has failed, if the aneurysm continues to inereasc. 
to c.iiise troublesome throbbing, and numbness of the lingers supplied liy tlic ulnar 
in ive, it is best trcateil by excision after ligature of thie uhiar artery alM)ve unil 
iiclow. The skin having been thoroughly cleansed, and an Esraanili's bandage 
applied alKive. a longitudinal incision, two or three inchi-s long, is made over the 
.-welling, diviiliii)^ the skin, palmaris bre\-is, and palmar fascia. Any tendons and 
the ulnar m rve are carefully drawn aside. The ulnar artery is then tied with 
slcrilisi-d silk or eaftjut alioveand below the swelling;. The sac is next snipped aw ay 
with scissors, and, if needful, the (h'l'p branch I'f the ulnar artery is lied also. The 

' The wound suniitiiiu's ilues not bleeil when examined. If there i.s a history of 
laiM li l>|(.ediii»; and if the depth of the wound make it probable that an artery is injured, 
pn -sme .*lioiild be applied. 

- An instructive, treated successfully by incision of the sac with interesting 
:riti:irks on the pathology and treatment of this dif^ease. is r corded by Dr. J. Griflfitlis. of 
Umbridge, Uril. Med.JourH., 1897, vol. ii, p. tMiO. 



or Ihnv .lav-. l->.t tt 

wound itlHmW .1 m '"•'"'">■ , which hnvi- r.-.wj.'.l ' 

WhIW Ihr »Ik,v. .....rsr .-. ''■■';''>',, rmlwl. will li..»»«.-i»'nt in |Mlm4.r 


Tu....... .K.un, j;;*- 

bodieM : Ci) t H. funKnt|M*: f....u 1 ' Z^', H^MWra-oH 
tion ti«ue ex«.t u. an.l pn. . t . ' . m 
wherr there w a . hroiur >. m^^^ 

w.>„na bo not kept irnifficlt toVen.oie all 

tl... •• mrln„-s \ - iMMlios whirl, aiv ..ft.;n pre- 

S,,.„, i„ ^roat al.un.ianr... ..r all tl..' <lis,-as,..l 
sviH.vial m.-inlm.n.'. l.'.) A .■...>.i.....n.l (.alma. 
.an.-li..„i8 vm- oft.-.. tuh.Tnii..ns. In th.-s.. 
th.. disoum. i« very likely eventuallv t.. 
^ ..xt.-M.l to ilH- arpim. The arrangfim-ut ol 
/ tin- s> iH.viai slw atl.s of th.- fii.j.'. is ,s Hhown m 
/ ''""Treatment. A ciMTati-.n sin.i.iilv 
adviseil for com|M>uii(l palinai naiifilu-n <)VMii,U 
to the froquencv with «lii< li this .hst-asi- m 
tuberculous, and its coiis...,u..iit dangers from 
its surroundings. But as, in a few cases, this 
di-sease niav be of a chronic inflammatory 
^ ... nature, and as the sur-.-o.i nmv not always 

Im' able to avail hinisMf of th.- skill.-d assist- 
ance. &c.. which i.s an absolute .v*/.. fo, tho radu al ''I"'';';-;'';; " 
simp .'roiM-iation will be first described. It i.s not r.-c-onma-iid... . and any 
o ' ., it must r.-n.e.nber that if he fads to cure t .-e disease, he 
w 11 ha -e rendcvd subs.-.,"."nt needful st.-ps murh more dithcult. 

A. The parts having been rendered .sterile, an incision shonld be 
made an inch above the anterior annular ligament, avoiding' the medun 
m rve, and going down into the ganglion, the •'I''--'^ V''! I' .;: ;''•!;., ! 
not to be a m-iv button-hole, but must be kept free an.l .li a .-.1 1 h. 

e l. Is of the fr p.-nin,- into the ganglion being heUl apart by is.sue 

f«rcep. all the • n.elon-seed " belies ^^^.^ nrt^}T^\ I 
pressure, partly by the use of the curette, which sh-uM expl...e all th.. 

rcpcaii.lly ki.oiki-.l in sUiUttg some ongme-gear. iiw im*k->"- 
artery »loiie won tied. 

COMPOI Nl) I'AI.MAU (; \N(;i.H).\ «1 

, iivitit'M into whirh thm- jfitiiKlia ar«> wkiiiotinioH (liviil<>)l. The *, ' <tion 

'i| |ir<i\ iiliiij; a hitihiiI <)|ii'iiiii'.' Iicliiu tin- iiniiiilar liuMiiK'Ht will now 
jll.-u'. Wili'll till' }.MIi;;li<ill IS liirv'*' iiliil wlicil the " tiK'jnii Hfcil " lMMii)>H 

.111' iiiimi'iiiiis. II .sfcdiitl ii|H'iiiiiL.' sliiiiilil rcrtiiinl ■ In- iiiiiili-. 'I'liiw iimy 
III' ildiH' l»y |nn««iii)i H tlir'Ttor hi <|i'i-s.siii^-fi>r('i>|is .hmi tin' iipiMT i)|M'iiiii'_' 
iiniliT the aiituiliir li};aiiiont. anti riitt' i ili>\\ u|iiiii it tlinni^'li tin- 
|iiiliiiar fuM'iu. vurv lieiiig tukt'n Ut avt^.tl I* HUiM>rlit'ial arili. TIiIh 
i.|M"iiiiiif huvinn Jm'pii pnlar^vl with th«> h«'l|) nf tln' •In-Hniiijj-fom'jm 

I II' rlirrtti' is ;i;,'aill .1 |i|>lii'il. if lli'i'ilflli. iiIkI wlii'li. I'itlii'l' liy tlltit iimuiiH 

111 l)V nililiiiiji lictwci'ii till' i>|M'iiiiiv'H a sfiip ul stcriliscii ^mv/.f. all flii' 
■ i)i»'l<iii-sci'(l " hiidifs arc (li'tarlit-d iilid ifimtvi ' I. tlif cavity is washed 
Hilt with a stfiilc saliiH' soliitinii and tlit'ii. I»y pii'ssiiri'. an*l tlf a|)|)li«'a- 
timi of Mtcriiiscil pads dried hm thorou^ihly as poH.silil)>. 

A uiuiU rubbtT tlruiiiafit* tubt> may hu iiiHerti'd for a few ihtvtt iM'twovii 
the iipp^T two of th«» intpmiptwl 8ilkworni-i!iit HiitiiK s whirh chm«' thi» 
uiiiiiid aliovc the wrist. The liaiid and fiiiiaii;i may In' cniix I'liiciitly 
put ii|> with the liii;.'cr.s llcxi'd. as un a I 'air's splint. I'a.ssiv"' nmvt' 
iiii'iits (if til'' tiiifrrrs should In- started at tlic did of a wi'i'' 

|{ A iiiKif radical opcratiiin siioiild he p<-rfiiriiii'd practically 
I'M'iy case. iiwiii){ t<> the probabi*' tiilifrciihiim nature ul the troiibU' 
.iiid the risk of thv iufeftion vxtt'iuitiiit to tho car|iu«t. It shoii!d rcr- 
laiiily he perfortiiMj whp« then" is r«'aw»n to .sHsjKTt tub^Tnilcus n>i.s< hi»'f, 
ul when the di.sease recurs. The i/anjilinn hiviiii; been openei' l>v the 
<le|>s (.'iveii above, but with much freer iiicisidiis. it m , lis will cc t.i iily 
III' foiiiicl to be thick and velvetv. pi'ihajis >li(iwi • ascular fi,ii<;es 
iiM'r the tendons. In .such I'li each of the tindoiis must be separately 
liiioked up and cleaneti with curveil. bliint-poiiited scissors and dissectiiiji 
foi< e|)ti, the tliseased tistme being removed in as larfte continuous ]>i<H-es 
as piLssible. To eradicate the whoie of the tulwrcidoiis synovial nieni- 
liraiie it will be needful to divide the anterior annular liirament. the 
position of the median nerve bein;.' first carefiilK noted. The four cases 
iriveii below, in which ttiis step was taken, show that no wcakeiiinj.' 
lit the liaiiii need be feared. The incision must lie lioldiv maile from 
aiioiit one and a half inches above the annular liijanient down tliroii};li 
this structure to a jwint just above the level of the superficial imlniar 
arch, fhherwise there is danger that, by iiiNufficient exposure of the 
part- persistence of the tuberculous mischief, and. ultimateb disease 
of tlie carpus may ensue. When bv the use of a blunt hook, dissecting' 
liiiii'lis. and blunt-pointed scissors, each indixidiial tendon has been 
rieaiied as tlioi'oufihly as possible, the sui;:i'()ii examines for the presence 
of lione disease, flushes out the cavity with hot sterile .saline solution, 
fdllowed by rubbing in of sterilised iodoform emulsion. During the 
operation every bleeding-point must be secured and li<;atured. The use 
■ it forci-pressure is less advisable owin^' to the risk of (lama;;e to the 
ti iidons : general oozin<; is checked by the hot saline .solution. The 
iimular li;.'ament is then united with buried sutures of catjxut and the 
ilie.ssings are, when the wouml has been clo.sed. applied .so as to exert a 
iiiiitorm pressure. 

Two more points need reference. First, as to the use of a to,i! .jiquet. 
I his is not of material importance. The after oozing, always 
Ine. will be especially so if this, or an Esmarch's bandage, hv 

' If (111 I'littin;; into the uiuiglioii il» wiill i» fuund tu tip thick, velvety^and vasi'ular 
I iii> o|)cntion is certain to faiJ. 

.gloved. Drainugo .h.-uM '-^^^e^wS are^eft untiM j.t 
botUn two of thes,lkworn.-gu « renumnl an.l t 

th.> uppor «-na of the wou.u _ I tu. ^^^^^ ,„,porn.nt 

sunJ\ M after tAV.. ''V*^'*'" uln, at. attontion. and that w 
,,„i„t is <..,.■ whirh has no ^^' ■X^;'; ,/ polli. ls. There are 

nsuallv two synovia .^f i the median .u-rv. th.- other to. 

the fh-xor t. n.l-.MS th. f^^ j^j.^ may conuounuat. 

the hnn Hexor of tl><Vl'"'';'.;;„,]X C- 'hove th^ 
with the f..rmer. extends J ""*'''' ''f ' , It in not always mvolve.l 

,.,,,,.l,aseoftheungualphalanx tth^^^ i„ tbeeas.s 

i„ tulMT. synovitis of 1"''" ' " in the thenar eimnenee 

„„,,„l„,,.,l l„.lovv it hiul escaped. In tj . m , „, „, 
tl.i..i<..nin,al..n, the t-''7, ^ ^ , ^ 't l.-s of the thumb. 
tuherc.uh.sis. 1.. -..'I'M to j'V'' '1 'l^^ ^^^^ tUiekene.l tuhen u ous 

thesheath was laid open ''''7, ' £ ' Vii.eans ..f a c urette and strips 
nuMobrane there was removed, a ; ; passed hv means '.I 

.,f sterihsed gauze soaked ' > ; ^ ,,,ow to that al,ove the 

.sinus-forceps from the opening o t > . m ^ ^^^^^^^ ^ rubbed 

„„„.lar ligament, diseased .j nm ml .^ '^ b„„„th 
,,vav as far as possible from that imrtot t ^^^^ .vnumls were 

th,. inuseles of the thenar „ver these, un.torm 

hc.ale.l collodion dre.ssmgs -'■7; ^ .■ ,, (ir.nlv -ver the thumb 
pressure with strapping. '4>lJ'^ ^1^^^ t,„. h.ispital. and remaine.l 
The cure was complete when the ^ ; '.^e.! since the nper- 

s„ {rid. inira) during the six n>ont « ^ ' ^/^^ .,f ,i„, must be 
..inn. -Vfter tl.isoF'^at"'"^^^*^^^^^^^^^ together of the 

also be carefully earned out. (acohson divided 

I„ ,he foHowmg ^^J^ , ,oma„. 

annular ligament. ' Ihe Y?^- ' , . ^.,„i,roidei v. 

earned her living by working at to.v ^ ■ 

Wright, .hose l-^-'t**^'Th?;rS pXt The patient had followed 
1(»()4 to show the result. . This >^a8 peneci \ ■ „, ,,i,,|„sis 

„.,• ..n.i.lovnu.nt ail the tune, but so ^ i^.^^^ ,^ 

!;;'tb.v.ft lung. Ti. second ^ ..^i tiuckeni.^ 

verv melon-see.l ^ ' in which tubercle 

svnovial membrane was pre.sen . tl' " ^ ■ «J th s patient, one and a half 
,;acilli could not be found. ^ '('^.,^,^1*';: as its fellow. The 

v..a.s after the operation, j^^"'; ^^^'^^^ 

^,,i,a an.l fourth patient^s r^.^f.^lta h " ^^e tlexov longus pollicis was 
. coincident Iv, in I W In both the ^1' Yients ^x^e a grocers assistant : 
„,arkedlv iiiv..lve.l. Both were y''""f P'^^^bX'e bv a .single incision 
he other, a barmaid, had been opera d " "^^^^^^^^^ i.^.eased the 

above the wrist. This fact, the ^'^"^.J^,. the man wrote 

aitliniltv of the operation. In answei to 11^ mc^i . ^^^^^^ 

to me as f..llows about six f ^ fSt of it. The 

nuite strong, much stronger than when I hrst u It a , ^ 

L joint of the thumb is st.ll stif^. and IjJ^J^ f se {'i \ ^^^^^^^^^ 

\.Was the other. Otherwise it f « Pf^^J^ 

to the fourth cas.., that olthc^barniaKlD^ ^^^^^ ^ ^^^^ 

after the operation : As tar as 1 taii , 


."):>. who 
in June 


iiiwsible. She haa regained all movements of the fingers, the grip of 
h." liniitl is a little weaker than on the sound sidf.' 

• TliP above rases prove that, with skilled assistance, there need he 
,,, lirsitation about division of the annular ligament. With regard to 
,,v ti viitiiK'nt of tlip flexor sheath of the thumb, six months is insufficient 
,, ni<,v<' aiivtiiinf;. At all events, the example is worth following. If 
•lie method prove incomplete, I should not hesitate to divide tlie miiscli' 
md lav open the whole of the sheath. .\ sound hand, at tlie cxpciis.' 

I ;i less mobile thumb, would certainly be preferable to jjersustcnt 
:,il„M(ulosis. matted tendons, and invaded wrist-joint with .smuscs. 

s.condarv tuberculosis in the lungs or elsewhere. Should tuber- 
, uliiiis tciio-synovitis occur in the extensor sheaths at the back of the 
uiist it nuLst be treated on the same lines, i.e. the .sheath be 
t hoioughly opened up, the diseased synovial membrane clippeil or scraped 
nw ly. any pockets thoroughly curetted, and any bony focus completely 
>( ni|i('(l out."' 

Treatment ot a simple ganglion. These , ill cysts, which most coi.iinoiily 
,, , III in coimection with the teiulon sheaths at the back of the wrist, are variously 

, as (hie to local teuo-syiiovitis, colloid degeneration of the synovial mem- 

i ,,',, I lii i iiial iiiotriisions of t"he tendon sheath, or in some cases from the synovial 

„„ iiiliiiiiie of Hie eai iwil joints. Should simpler methods, such as the application of 
„„liiie. pressure, or incision with the injection oi a few drops ot pure carbolic fail, 
ill.- •jiiiirlioii should be excised. 


As ill tlie case of divided nerves, the union ol divided tendons may be 
primary or secondary, ucording a.s the .surgeon sees the case at once 
or after an int.'rval This injury is especially freijuent and of great 
importance in the to dons of the liand ami wrist. 

Prelimiwtrii om demlktm. (1) The diagnosis usually presents no 
.!iili. iilties. there will be entire loss of the movement produced by 
ii„. injured tendon. Loss of power may residt from injury to a motor 
ii. i\e. imt ill this case there will probably be some anu'tithesia. and 
. lectrical stimulation of the miuscle will produce the lost movement. 
, J) When a tendim is divided there \\ill certainly be some retraction of 
the proximal end owing to the tonic contraction of the muscle. .Mr. \ .\\. 
Tiilibv ' points out that in the c;ise of the extensor tendons of the fingers, 
there will be but little retraction if they are divided at the back of the 
h iikI Ol lingers owing to the connection between the various tendons, 
th. ir Miiniieiiiotir expansions, and their attachment to their sheaths. 

I I the extensors of the thumb are divided at the back of the wrist there 
is but little retraction ; if. however, they are divided at the back of the 
metacarpal the upper end may retract as nmch as three inches. In 
the case of the flexor tendons there is but slight retraction, owing to the 
piiseiue of the vincida; if they are divided over the phalanges; there 
I. also but little separation if the injury occurs in the palm, but if they 
.lie divided above the wrist great retraction of the upper end is to be 
■ xpei ted. (:$) It is necessary to insist upon the itnportance of immediate 

iiluiv. If the injury to the tendon has at first been overlooked the 
dilHcidty in Hnding the separated ends and bringing them togeth»(r is 
much increasetl owing to obliteration of the sheatli and matting of the 
» /A/«mi/iV«, 1812, p. 769. 

94 OPERA Ui». ^^^^^ ^.^^^ 

te.uloi» to surr<)umUi»g ^^"'''."'Ti.w to o'lcli <.'tl>er or to a cicatrix will 
hat a.lh. slons of tlu; flexor t<^"*"' , !r ' (4) In all these opera- 
certaiulv prevent full ^« ^ fo,^ A tendon has a poor 

a:-Jfl3:Vr^=^- infected, sloughn,, . very 

"''tiX^^ke of ...nvenienee. operations for the union of d»v,ded 

A. Cases where both endi can »e ,j j j,,,,!,;,,,, enlarging the 

aajusted. If the injurv ,s recent a l^t,"^. e eases ^vl.'■re the 
Original wou.ul will usuallv be '^'^ J"VLre atted together a Hap 
injSv is old-standn,g and the tendons are nu ^^^^^^^ ^^^^ ^^^^^ 

Jy be preferable. with a sharp k.nfe 

tissue is ren> as ' >: if '^,,,ii,,^ the distal or fixed end of 
„r scissors. There .s no it ,nav be sought 

th.. tendon. »h"»''l» '''r"-;''"'l r i ; '.r >"^terial for 

,,„, ,,v „f the t^ for twenty days : 

nritlS'r.:''!^ a"c«uU edge are very UUely 

to tear tl'roug»i/he daumged t^^^^^^^^^^^ ^^^^ „a 

Methods of insertiog the sutures ^^^^^^ j^^^,^^ j^p^^re 

..ither of n>e.liun. or large size, the mi j^^^,^^.^,,.,,^ 
ha. kwards throu,h ^'""^'7 ^"^ 1^^^ u 1 ^snpertic^^^ surface 
through the other, and '^.'^'Sf^ee^ with two lateral or 

„f the tendon. "nailer tendons with one 

^nth one central and f ' ,i,,„„„ed the ends must be 

„„nlian suture onlv. As ^ ^„ „v,.,,ide one another, 

kept in exact appo.smon. » ■ J ' , \.anMn^^^^^ 

I,, tins method and m the "^hers win b'"^' ^ ,^ tendency 

,„ i.,ert the sutures too "^^f^^^T ^fuarallel fasciculi : this 

for the sutures to separate ' * t^^^^ if muscular contraction 

SllJ^'iv stS::;; i. very UUely to take 

preferable. , . ^.^^^\\ for the methods 

^ (3) men ty tnnh,n ,s ''''^''j''^^. . ,f the tendon and 

of Wolfler or Le Dentu. and . ! „ut. Schwartz's 

the tension, a-ture inserted in tlie o d, ^ -^^.^^ ,o,,d 
nietlKxl mav be tried (Fig. Ai). A . h)ngitudinal 

each ten.l..n end a short distance from th-"t urba tw U^^ ^^^^^ 

sutures are then passe.l aboxe ^^^^^e^^^^^^ An objection 



■ .fliMiirily iij)plii'<l iiitcrnipted sutures to cut out too (|ui(kly : " TIk' best 
1.111 is t<) pass the iii'ivUe across from front to back tlirough the whole 
iiu kiK'ss of til'" tciidon (juite to one e(li;e of it and close to the line of 
1 vision, and then to tie the thread over the 
I 1,1 11 piece of tendon included in the loop, 
vi; hniiv'li the jiiece of tendon below the lipature 
. ,,\- piissiblv <lie. a secure hold is thus ob- 
.liiieil. which iiiiiv be |)ulled on tirniiy without 
,.,n- of the tliread ciittin<{ its way out. The 
line procedure should be adopted also on the 
.pposite side of the ten(h)n, and both the uppt r 
,ni| lower ends should be ))repared in this way. 
iiir liciiitr takiMi that the .stitches are inserted 
,! exactlv corresjioiuling points in the two 
lids, so that the tendon is not twisted when 
iii'v me tied toj;ether. Tiie ends of thecor- 
, r.piiiidiii,<; threads on either side 




Vhi. W iillliT s transvi isi- 

tciiiloii-siitiii'i' ( It'll ». Mid. 
HVA., 1H88. .■>. I ). When the 
ends touch, the inventor ealls 
hlMmpthtHl "ilireet transvrrso 
tendon" Nuturc. and nivcs it 
thr niiinc (if ■■ iniliri'ct " wlirii 
llii i nils l aniiiit 1h' lir(iiij;lit to 
pllicr. and till- tliri'iids arc tied 
and li ft til form Kuidcs for the 
dcvrlii|iiiii'iit of fihroiis con- 
iiri'tiii^ lirid;;i's. 

the (/ivi- 

>ii)ii are then tied sufficiently chjsely to 6riug 
1 lie two cut surfaces into apposition. It is well 

til put in one or two stitciies in the centre to 
iritilorce tiie lati'ral ones; will prevent 
til.' cut surfaces from being disi)laced laterally 
Ml nuleil up. and as they do not bear any strain, 
\ iiKiv be inserted in the usiud manner." 

Wlien the divided tendons have been united and all ha?morrhage and 
iMi/iiiL' have been checked, the wound is carefully sutured. If the wound 
uhi ii liist seen is tliity. or if after-collection of blood or serum is thought 
ihle. a small drainage tube should l)e inserted. The dressings .shiudd 
p|ilii'(l ill siitticieiit i|uaiitity and uniformh' so as to e.xert even pres- 
If po.ssible they slioidd remain unchanged for seven or ten ihiys. 

The limb nmst be ar- 
ranged on a splint in 
such a position that no 
undue tension falls upon 
the united tendons, while 
at the same time the com- 
fort of the patient is 
attended to. Moulded 
splints of poro-piastic or 
gutta-percha are best, or 
a perforated zinc trough, 
which is readily cut, fairly 
easily bent and moulded 
to any degree of flexion, 
and which can be boiled, 
will be found useful in the 
common cases of tendons 
injured about the wrist 
where the elbow, wrist, 
iml lingers must be kept Hexed. If wooden splints be employed, 
t Carr's splint is comfortable, but must be reinforced by an angular 
^pHiitt«> maintain flexion of the elbow. Wooden splints ate, however, much 
ie.^s eitieieiit, iu that they fail to secure the needed amount of flexion, 

H. ('. 

Drntu's iiiethiid of tendon-suture. 
B. That of W illtlor. 
('. K. .SidmartzV niutbod. 
1 1^ Dentil ami llelbet, TmiV. * Chir.. t. iii. p. 825.) 


or the power of nuHlifying this later on. The paticiifs comfort will be 
greatly promoteU bv removing the splint every two or three days and 
altering the angles" slightly. Restlessness, while recovering from the 
anu sth.'tic. must ho prevented, for contraction of the muscle may cause 
the .sutures to tear tlirouL'li and the ends of the tendon to again separate ; 
if the .suture.s do not hold, the parts will tend to heal in one contracted 
mass. Most careful attention will be needed afterwards in tiie riuploy- 
ment of warily begun, and perseveringly continued, passive and active 
movements. In commencing movements the surgeon has. on one 
hand, to prevent the formation of adhesions ; on the other, he must 
remend)er the risk of breaking down the recently formed union. The 
date II ist vary with each ca,se. but. as a rule, in the case of the tendons 
of tht iiifrcrs." passive nioveiiieiit may be begun, very gently .so as not 
to .strain the union, about the sixth diiy. and gradually increased. From 
the fourteenth to the twenty-first day will usually be early enough for 
the commencement of active movements. Soft adhesions will certaiidy 
have formed, but if the sutures have been so placed as to s»cui" a firm 
holil. and if the wound has run an aseptic course, there is little risk of 
the uniiiii being broken down. 

In cases of .-iecondaiy tendon-.suture. as in that of nerves, the result 
niav be (li.sappointitig tor some ni(>ntlis ; but if the ten.sion was not 
extreme, and if the wound heals by primary union, the final result will 
probably be .satisfactory, if the patient does his best to help the surgeon. 
This opportunity may be taken to paint out that, in the treatment of 
incised wound of the hand or foot, the condition of the tendons should 
be cleared up as well as that of the vessels. Too often attention is 
directed .solely to arresting the urgent ha'niorrhage. especially if the 
situation of the wound does not exactly correspond to the course of a 
tendon. The wound heals <|uickly. and then attention is drawn to the 
I08.S of power. The following is a g(M)d instance : 

In August, 18K8. H. P., tpt. 31. was sw-n with constant flexion of. and in- 
ability to extend, the last two |thalangfM of the thumb. A few inoiiths before 
he had Iw-en tn'afe<l for Hevere hn-niorrhage from an inciwd wound of the dorsum over 
thi' liist iihaliinx and mrtacarpa! of the right thumb. By dissection the exteiisor 
si-eiuidi iufcriiiMlii was foiiiid to have been divided, the upper end coming into view 
on following up till' slii atli. 

The oxten.sor bn vls had lici ii oTily pailially diviilid foi- tlii( (' i|uarl( rs of its 
width. When Iriiiiiiud the two i iids of the i xti iisor sc< mxli wt rc st |iaiatc(l by an 
iiitcixal of an im li 011 (uriiplclf cxtciisioM of t\\r tlniiali. I?y the use of a stout 
siiliiic. and by laisliini; down the iipiici' end of the trralon. the ciuls were brouglit 
to within a (|iiaitti- of an iiK h of one another; two line sniuris then brought the 
ends into good but not exact apposition. On hyiKf-extinding the thumb the V- 
shaifcd uoteli in the i)artially divided extensor primi was obliterated, m no sutures 
were used here, the edges of the notch l)eiiig merely refreshed. A splint was applied 
on the palmar asiMtt. so as to keep the thumb hyper-extendcd. When seen two 
iiuMiths later, the patient had recovered complete power of exti'nsion. 

15. Cases where only one end can be found. The distal m fixed end 
of the tendon can nearly always be found. The difticulty of finding 
the upper retracted end of one of the flexor tendons may often be extreme. 
Should it not come into view on slitting up the sheath ior a short distance 
one of the following methods may he tried ; (a) The muscidar bellv 
may be pressed dow n by manipulation with the fingers, or an Ksmarch"a 
bandage may be applied commencing at the elbow and passing down 
wards the wrist. (/)) M. Felizet advises, if slitting up the sheath 
iiiul methodically pressing down the muscular (telly are insufficient, 



that the uppor end may be made to emerge into view, and further 
ilisturbance of the parts avoided, by extending the adjacent fingers. 
Hy this step, what M. Felizet terms the little fibro-semns vineula, which 
tic tojtcthcr adjoiniiij; tendons, arc diiiwii ipon and j)ull wri the 
ii|i|)cr end of the severed tendon into view, (c) Wiien tiie tin^ u|) 
(if the sheath would have to be very extensive, and niij^ht involve diiii;i<T 
to important structures, Chtnne an<l Burgliard that u second 
incision be made over the tendon well above the wound, and the sheath 
opened ; from this incision the tendon is pushed down by means o{ sinus 
forceps until the divided end appears in the original wound, (d) In eases 
wiicre difficulty is e.\|)erieiiciMl in finding the distal end. c.//. in secondary 
((|» rations for divided teudon.s at the wrist where the pro.xinial end is 
liki'ly to be fi.\ed by adhesions, the same writers advise as follows : " A 
lii'tter plan than di- 
vidini; the annular liga- 
ment is to cut into the 
palm and expose the 
tendon well on the dis- 
tal side of the division ; 
tlit'ii. by ]iusliiiig a 
probe up tiie sheath, 
the [Miint at which ad- 
hesion lias taken place 
may be found, and an 
attempt made by for- 
cing the probe upwards 
through the adhesions, to make it i)rotnidc into the wound, and form a 
guide along which the tissues can be turned aside until the end is 
reached." (c) The only alternative to methods is to make a 
prolonged dissection upwards, dividing the sheath, the ammlar 
ligament, and the muscles, but taking the greatest care not to 
damage vessels or nerves, until the proximal end is found and freed. If, 
after careful search, it is still impossible to find the upjier end. tin; 
lower end may be attached to a neiglibourinij tendon t)y tendon- 
anastomosis. This may be effected i)y one of the three following 
methods : {a) By fixing the severed end in ii bHitim-liolc made by splitting 
an adjacent ten(U)n longitudinally (Fig. :$?<). (b) Anastomosis by bifnrm- 
tion or splitting ol an ad]aeent tendon. 8chwartz describes a case 
where the proximal ends of two of the e.v tensors of the thumb divided 
at the back of the metacar|)al cotild not be found. The tendon of the 
e.\ten.sor car])! radialis longior was .sji it lonj/itiuliiially ; the outer 
ilivisioti was .sejiarated below and sntiind between the peripheral ends 
iif the divided extensors of the tlitimb ,Fig. ."M)). The following ca,se ' 
is a good example of this method, and of one means of employing sutures 
so as to prevent tension : 

An oblique cut witha bn-ad-kliife divided the ei)iiiiiiuii extensor <i( tlie iiulex and 
iniildlf tiiiger, and the exteiiKor indiei.s. the central emi of the hitter ivtraeling so fur 
lliat it could not be n-ached, unir -h by Hiittinp up its sheath. The ends of the common 
I'xtciwor were united by fine si! itiircs. The |H ri|)heraI end of the extenMor indicia 
WHS attached to both em's of the duture<i tendon from the exleii-sor coinniunis to the 
index linger. The strongly stretch'.'d extensor tendons of tlie second and third 
lingers were now fixed (to prevent retraction by musuulur action) by sutureM post 
- cm. higher up, through win and tendon sheath, and tied over a strip of ^usu. 

> FHIenUttm, Wien. Med. Woch., No*. 29 and 31), 1H83. 



Thc-so wen- r.-.nov.-,l on the tifth day. Ta-ivo u^nyM was begun on th.-mxteonth 
day. Six months later tho man hud prrf- . t u:,r of Ins lmg.T«. 

" The back of the hand is the favonral.le .situation for the 
.nastomoBis of tendons, as they are here unite,! by f, brous ' ^^"•^H.ns 

Thus a neiRhbounng tendon t an lie relied 
upoti to render active the perii.lieral end of 
another tendon whose central enil cannot i»e 
found. Kiirthennore. it is on the back of 
the hand, ami e.Hiiet ially near the knuckles, 
that operations on teiulons "ive the best 
result*. Retrat-tion is less lieie than else 
where, owing to the preseiuc of lonnettin^ 
bands and expansions to the joint tapsules; 
there is less bleeding ; the skin is thinner, 
anil its fireater mobility renders less harm- 
ful tiie fonnation of anv adhesions. Hut 
while tendon anastoino.sis is especially applie- 
al)le to the e.xteiisors. the following; ease, in 
which Mr. F. T. Paul' joined the teiuhai of 
the fle.xor longws polHcis to the intle.x temlon 
of the flexor profundus, shows that it may 
also be employetl in the case of the flexors. 

A lioy. n't. 7. had sustained a ^rvi iv l ul ai lo^s 
• he'liall 'of llie rif-'lit tlmnili. 'I'lu iv «iis no i 
(iv. rlhc last joint, and <onsi i|Urntly no powi i' ol 
hohhiif; anvthins; ' a l>< n in tli.' usual way. 
ini isioii over till- Hcxoi lonuus n vealiil the distal 
end of till- liiidon in yood (ondilion and lirnily 
attaclicd t.. the scar. 'I'lic irnlral end was sought 
for. but llioujjh the incision was piolonpil an Iruh 
alHJve the annukr ligament could not he found. 
riiiK r thesi- cin-umistanies it was decided (<« form 
Kio. S!t. Tondon-anartomosis an aiia-stomosis U-twven the tenuinal end of th. 
hv splitting or bifiirfBtion of an cut flexor and the sitle of the index I. i.don of tl , 
adjaciirt om«. Method of M. E. flexor IttoftUHhw ; a step w hi. li. if sii. , . ssfiil. wouM 
Schwartz. (Dpntu and Delbet.) give the ixitient iiower of llexiiic the timinl.and fori 

tinger together, and thus of lioldinn articles helwei ii 
them. The free end of the thumb temU)n was inserted into a notch made in tic 
side of the index tendon, where it was tixcil l.y two or tliivc sutures. .\ ycai 
later it was fouml that not only had the l.oy tlic eon, Lined |.<mcr ot i.'r.i>p liopi U 
for. but that, under training bv a skilled pianist, h,. was oljtainm- imlcpcndeni 
movement of the thumb and forefinger. The fa. I that, wliil.' the l.oy hml ..nlv 
one muscle l«' th.- two digits, he . oiil.l yet lU x them separate y. was entirely 
due to the training of tlu- extens.)rs. Tims, if t.ild to Ik-ihI the thumb alone, he 
would fix the forefinger by its extensor, and then Hex the thumb, or the reverse. 

0. CaiM when both endi ean be found, but it U impossible to adjust 
them. This difficulty is usually met with in some cases of secondary 
tendon suture, or after the removal of a growth which has btcome 
adhet' to a tendon. The followino inethoils are available : 

(1 .<:ndon Lengthening, {a) Mitliod of Tnibi {V\i:. H). This may 
be tried in the case of large tendons. The loiioitudinal incision 
not be carried too near the end of the tenih)n. and to prevent the dis- 
placed slip becoming detached bv any tension that it may be called 
upon to bear it should be aecttred above as well as below by several 
fine sutures (Fig. 44a). 

> Liverpool Mti. Chir. Journ., 1805, p. 300. 


(h) .\frtl,ixf of C'rnn, ( Kii;. (U). (V,.TIi\ ill ;i nis.- ill which olH' of 
th.' .xtcnsoLs n| til.- thiiiiil) hiid Ihmmi (livid, I, lill,.,l up the <ii\\) liy 
spiittiiiu thf in'ii|)h.'ijil .Mill to the iv.iuiivil t'xt.'iit itiul ifvt'lsiiifr it, 
Mitiiiiii^' the lower iMid of the (lisplacfd slip to tlio iliviilcd 
(t'litrul If this int'thod be t'lnpluyed. ii ciiculiir 

suture HhouKi be insertwl at tho luifrle where fli.- slip is 
turned down 8<Mi8 to picvcnt its li. ini.' torn awnv. Slioiil.l 
tliishiippon.tfifsfpiiriitcil iioitioii ot tin- tciidoii isnlmost 
. . iliiin to sioiijili. A tiiiiisvcrsc incisinii is made between 

. III.' oi I wo inches above the fr. ml of the proximal part 

.if the tendon, according to the size of the };ap to be filled. 
The iiuision only goes across half of the tendon, and from 
this point the latter is split vertically downwards as far 
as a fMtint a .|iiar(er to half an inch from tli." cut 
.■lid. The l!a|i is then tiirne.l down, care lieiiii; taken 
iliiil It is iM.t .{.■tach.'.l. nil. I to meet aiiv fiitiire"(.i|isioii I'' . m r. ii.|...i 
,il ill.' an;.'le sutures are pa.s.sed and s.'ciirelv tied as ' '■> 
I "'"'v.v if nece.s.sary a .simihir flap" n.av bi- I'o i, r' Mi'Ii 
tiiiii.'d up from the di.stal portion of the temloii. Under I». IIm i.) 
tli. s.'cireiunstancesthe two flaps shoiiM be cut h.n^' eiioui;h to overlap so 
that sutures can be placed betw.'.'ii f li.'ir ontit'iioiis si.F.'s. II.t,. as in 

all when newly united t.-iiiions aiv siibniitt.'.l to .si tension 

III" parts be kept fully lelax. d for a sullicient time, active an. I 
II.I-.MV.' niovein.'nts l)e;;nii very ),'entlv. and increa.sed very jjraduallv 
W li.'i.' many t.'hdoiis r.<j. the fle.xorsof the have been lenKthene'd. 
It may lie w ise to defer active movement for a fortnight. 

In llw iiwUkhI of IIMs (Fiv'. f.-)) a h.njiitudinal slip is'tiirn.'d down as 
111 ('/.ernys method; further l.'iijitheninj; is tli.'ii .il.taiii.'.j bv splittim- 
this slip in a .similar fashion, tii.- tiansv.'ise inci.sio., Unw ma.!.- on the 
"liposite ,s„l.' ot III,' t.'ii.h.ii to th.' liist. and the l..iij;it miinal iiici.sioii 
<xt,'ii,liiif,' upwards towanis the cut (Fig. l',). The 
aiiiili's ii',|uire careful .sti.'ii^'th.'iiiiiy bv sutures. 

('•) Th.' ten.lon may be lengthened bv some m,-tlio.l r<..,uiriii.' a 
.11.1 transverse division of the tend<m. Some oth.'r in.'tho.l shouM 
po.s.sible. Im' a,,'<l. tor th.-n- is a strong; t.'ii.j.'iicv l,,r iIm' .s.'parat.'.l 
portUMi to sh.ugh. When the t.-iuhiii is thick aii.l i,i,in,l.'.l, .\n.lerson-s 

- 111. 't hod may be em- 

— ^ A ployed. The gap that 

- renmins between the two 

— ^ B I'lids of the tendon hav- 

i 11 b.' .' II ca re full v 

^ ^ ^' ~ ^ III. 'asiir.'.l. .'ach tendon is 

I'll- tl. (inc ni. lh.i,! „f ti'ii.loii-li'iiKthi'iiiiiL'. \. 'I'i-ii,|„ii i:!!'*'^' "i 

It .11.1s i.f lisKurt'. c. DiviilH tcmlun i'li»iii<at«<l awl taken not to bring the 
HHturt'd. (Amiersoii.) split t(H) near to the end 

,„ I f .1 1 • . . ""^ ^''ikIoii. .\t th.' 

luo ot the above meismn section of the hahvs of th.. 
tendon IS made, as in Fig. 41. 

Id) Trndon lr,,,/t/,,,u,,:j 1,,/ ;/,/-:„,/ ;,ic;.si„„s (Ki^'. 12). Poncpt has 
>li"wn that this metlio.1 may be .succe.ssfullv eniploved in cases where 

mg to the tension, the sutures threaten to cut through. 

In the fint caw, that of a boy whose tendo achillia had just been severed. 




1„o OI'KHATIOXS OX TlIK I PPER EXTREMITY tins .n.'th.Ml is C8p«-ially apphoal. t.. t l..- 

a wavl pass th.-.u.-h at 1-ast half the vv.c th «f the ten- 
don? then- is .... risk of tl... t..n.l..,. sl.„.gl..nt: .f al pn- 
O..S are take,, to avoi.l i-f- t..... of th. w..u...l. 

V..n t I " also .na.le u^e of the foll-v;">J 
;,;..tho,l I.., ....itii.f.' a sevenMl ten.lo achiHiH (Fir. 4») . 
v .,., tl.Miiiurv (1>\ iiii.«x. )tln'Wouinlwni» hfiilwl. 

!. ,';,s„i..n«itl>on. a,ul,..... Msi„n, Th.- rc-« was ,h f.H. 

(•J) Distance sutures. (") • , V, 

i.. where the "f the_te,.aons_..o..hl not^lH; Vu^^U.^^ 


:.:i-;::,:::i:"ti:: wiaeiy se,.an.te.i -^':::-j;^.n;: 

cuds havr licoii joiiK'tl by stitii.-e (i'onf«-t.) 
loops wl.ieh have appeaivd to 
.Uminish nuiwular tenmoi.. a.i.l to help ... .li,v. tm;i 

the pnK-e88 of repair, t'ut-fii.t aii.l (....■ .siKe.' Nvin- 

have been en.ployetl but (.s<r 

f(.(.tiiot.'. p. UMi) is reeonimemleil by Mr. lubbya.s 
til." most satisfM. t.)rv material. 

Distance sutures s.'.m.i t.. have be.-ii ei.iph)yod 
i„ this e......t.v as \nuii a^o as IWltt. by Mr. Gost- 

linft. ..f Won est. r.' ii. a of injury to the ex- 
teiisois ..f the thumb. 

Kl. v. ii w.cks iK-foiT. whilo the imti. iif was (....niiij!. Lis 

kr.if.' i..HiH«l a vv..u.ul. tl..' ..«.■ ..f whi. b. a., hu h 
tvas f..u.Hl an i...l. al'-'V.' H-.' "f • ...; l^- an'j' "f «l 
Mt thumb. .Iii^-t hv\.ny this M-ar ihv .hstal .-.uls <.f th.- .a- 
eiisor primi int. ni.Hlii aii.l . xl.'.is...- .isms .n. la. ar|,. ^ 
Uiwor primi ^ ^^^^ ^ ^^^^^^ UUJmt th," .'i - 

(•■.iil.l oiilv hi" iiKhstim tly iniul." out, tiv." 
inih(s.itl.'c>iith("l>aik<)f thofoifann. Thi" 
li ft haii'l was si riimsly ci iinilcd. the thuinh 
liciiij.' Ilcxtd ami a.l(lii. ti"(l i.ito ihi- |Milm. 
All in. isi.iii ("xi)oh<"<1 the dUtal ends at once, 
hat th<" sviHJvial shcnth was blocked for 
Tu 4:t Suture of tcmlo aihillis t)y t|,r(.t..qua"rtiT>( of an inch by scar tissue. 
parti.1l (l. tachment and sliding upwaijl This was cut through and th." sh."ata slit 
of the OS cakia. Poncct's method. unfjl the proximal ends of tlic t.n.lons 
(Duplav and Reclus.) wre found. All four ends wnc smoothly 

rouiuU.l ..IT and no adhesions had formed. As the emls w.M-e "ve inches apartit 
"imp^iVle t^ them nearer together than three-quarters of an mch. The 
> Lancet, vol. ii, 1890, p.J67. 



pndu hariag been paml. the rorrcHiiondinK rnclH were imitid hv two rnlgut autnrm. 
TIm' wimiwI hralrti by |>rimMry union, ami nix monthH laUr alt tlu- inovrm«*nlM of 
till- thumb wf>n* pmM-t. 

M. (iliiclf. uliri lias cmiiloyi'd tlic iiii-tli(iil of (listiinct' siifiiics with 
niaikfd .su(Cf.s.s in sfvcral cases, used it in (in*> instance not for 

tilliii<{ up a <;a|> in u tendon, but for n>- 
placin^ uti end which wiih lost.' 

A lioy hml the tendons of llie exti iisor iiiilirLs 
nnd the extfnwir comniuniit diviiicd us the result 
of nn injur>'. The central ends were tied with 
l<M>|w of silk which wen- earritMl to their tiointN of 
liisei'liiiii anil lixi'd l>y nieiinsof ii ste*-! lu-edle. The 
lirst trial failril. the siitiiri'M IcmiiiK out. A si r nnil 
i)|HTatii>nsiii ( < i'(lcil. When thr ni i'illr was n miiM cl. 
at till' mil of fi, M- wiM-ks. Isith the iiilddh' iinti teriiiiiuti 
|ilialaiiges eiiiilil Im' extendi'd. 

Ill another case in which the two ctidM of 
the flexor ten<h>n.s «)f the niiddh* fin<rer were 
widely separ.ited after an injury. .M. (iliick - 
was alile to leuiedy a jfap of III r in. hy the 
.siihstitiitioii of threads of silk and catgut, 
{{eaiiiifiiiy first intention and tx'rfect rcHtora- 
tioii of inuvenient followed. It wan thought 
that in this casea f^radiial substitution of the 
catpiit hy cfHinective tissue took place. In 
iitlier cases the foreiirn hody employed remains lon^ eiicvsted in a slieatii 
III cimnective ti.ssue. In all tljese operations strict asepsis i,- . of course, 

Tendon-KraftinK. Here a portion of another tendon, from the 
s,iine patient, in cases where there ha.s been an extensive injiirv. a.s in 
a partially crushed hand, or a tendon from an animal is made use of. 

Mr. .M.iyi) Hi. lison 'siii iTssfiilly grafted fnuraii.lii half iiieliesof a Ih .vor tendon from 
.1 liMiirrlDi. iniuh .smashed to save, on to |Ih> dontuin of t he htiiid. sous to forniu IK'W 
lAliiisor for the iiiilix 
liii)fer, the teiidiiM of which 
had lieen eoinplelely torn 
awiiy. Th<^ proximal end stitched to the Ik'IIv 
nf ilic extensor eoniniunii*, 
uhcrc the missing tendon 
lii'l liii'ii originally at- 
i.ii Ih d, the distal end being 
ti\ci| to the small |H)rtioii 
I. fl its in.scrtion into th 
iif conservative .surgery 


FlU. 45. MetluHl of Hiblis. 

phalanx. The which is an e.\eelleiit instance 
. ended in recovery with it mmt useful hand. Durinx 
xti iision of the index the new tendon could be felt to move under the skin. 

(iiafts from teiuhms of animals are extremely likelv to slouj;li or 
t" lie alworbed. Kven if no suppuration occur the grafts, in all prob- 
iliility. only act a8 conductors for new fibrillce as in the case of distance 

Dr. Rochet, of Lyons, has described a case in which he successfullv 
practLsed a method of tendon-grafting, which he called ;mtoclitlio!ious 
the ijraft being taken from one of the divided lendon.s theni.seh es (Fig. 4(i). 
This method is especially applical)le to the flexor tendons of the fingers! 

' Srmiiiu Mf ficale, I8!)2. p. 193. Luc. supra cit. 

" C7tn. Hoe. Tmns.. vol. xxil, p. 291. 


Tho pntirnf hnil. two monlli- 
the I<M>t of liis li^rlll iliili x linU' !•• 
all |M)Hi r of tli xioii Im mii: U»t 
iM tWcrll tlir tliviilril ( nils » lii( ll 

fM-forf. Miilfri'd ilivision of Ihf Hexor trndom at 
riii lH" lowi i plialaiim x wfriMimKliuilly ••«l«lKl«Hi. 

At 1 1 iN-nilHin mi iiilpnal «rf « rm. mm f«Himl 

liy no im niw (-ouhl Im- n-^liienil l«» him Ihan 2 t-m. 

T» till tliit Vii\< nil inriflon uiis iiiiuh) 
ovi'rfhf lowi r |Mirl of the inlilillcplialaiix 
iiikI tlic liasc of (111- hist, just wfiiTr till' 
lliAor |iii«fiiiiilus i iiiriL'i's from U-lwiM'ti 
(lir two sli|is of till' Miililiiiiis. I>r. 
Koi'hi't ilivlili'il till- foi'iiii r. .'iiiil tlii'ii. 
irtiiiiiiii!: to Ills lir^t woliliil. illi'W tlir 
pii ri' III till' lli'MU' |iiiifilliiliis. wlilrli W'ilN 
now rut aliiivr anil Im Ioh. ii|iuai'<U to 
lill till' ua|i. till- iittiii'liini'tits of tlir len- 
ilon to tlii'Hiicntliyii-hlliiK n'adily. Tin- 
lower i'IhI «»f till* t<>infcM»-»liji »i»n thru 
Hiitiinti to tlw (liHtnl cml of tin- tlrxor 
Ntililiiiiix. iumI its u|ii«'r <ii>l lo till- 
|iroxiliml cnils of tin' tlrMu- siililiinis anil 

|ll'ofutlllus llirirtiv In till- fiillllrl ti ll 
lion, anil lalti il\ til till' lali r. l/istly. 
till' small sli|. iif till' lli'Mir |iii>fuiiiliis. 
wliii li liail lii i ii li ft iittai lii il liitlii' last 
lilialaiiN. wassutuii il ti> llii- two slijis of 
till- lli'Mir siililiniis a litllr almvi' its ill 
si'itiiiii into till' plialaiiN. On the lif- 
ti Tiitli ilav soiiii' (KiwiT of llrxion wii» 
alfraily |)i('si'nt. Kvciitiially thi-M-cond 
|iiiiiliii'ix ttmkl lie tIrxMl aM fnvly lu* that 
of the other hnnil. KIrxion of thi-lhirti 
|thnlan\ whm niori' liniiti'il. Iliis nut pass 
Ing Im'voiuI a vriy oliiu-i' aii).'lr. 
; / Dr. Kiiilirt iiliM iMs that it woiilil 

111' |Missil)|i- til raiiA mil tills mi'tlliMl liv 
Vii:. 111. Aiili" lillii'iiiiiis ti iiiloii iitafliiit:. t.iliiim ||,|. uiafl fi'i>iii tin- pioxinial |K)f- 

(|{,., Ii. l.) r.. 111. liL'lit is sii n till' L'ai> ,| ~f t In- ill \ iili il ii hiImii willioiil in 

iK'twini till- ti Mili.ri- f,.,„.il 1.11 i Niiliaathiii: ,,.,.f,.,,|, , |,, i„^,.,|i„n ,„■ iiiakiliK a 

tothplfftthi'liiaiiiin Ml will, lilt «;i-lilli'.liip. j^^^i^ „,Tiiii.l. 

M. Desquiii has cleviscil aiiDthoi nu'tluxl of tt'iidoii-giaftiiig, by 
whirli tho «»f a flexor tendon was restoretl. 

\ 1 aipi nti r. a t. -'5. had th«- right inlcMIc tinp-r in |KTnmn<-nt i'.\t«'ii>iion. owing 
to till' si'vi'iaiici' of tin- Hexor tendoiiH liy liiokcn glaiw thirteen nionthH U-fore. A 
free iiii ision having been inade along the n.iirse of the ti iiilons in the linger and in 
the imlin. an interval of 4-5 em. was foiinil iM twei ii the ili\ iili il emlM of the »»|ier- 
tieial tendon, while it was inipossilili- to lind the ili-. p ti iiilmi. I5y sliimu tiartiim on 
the eentnil eiul of the sup rtii ial ti iiilon. it i niilil Wf liniiiL'lit into lotitai t with anil 
nuturei; to the phalaiini-al inil. This imilil only I"- iluii.' hy strongly llexiiii! th. 
finger, and it woiilil havi hiiii impossihl.' to iniltr th.' siipn lii iai pails i.\. i lln 
stioiiillv Hexed li iiil.iii. Hi liiiiiin;i to the wrist, thi ii fmi'. tin- opciatni iliMiliil tli. 
ti niloii with a small pic e of iiiiim le aillii riiiL'. 'I'lie liiiyi r «.is thi n exti nili il ami 
the tendon jiisl iliviiliil still In il to that for the index linjii i. s'l that the lli xor foi 
the latter, on its i imtrai tiou ai tril upon l".ili liii^i is. 'I'lir ivsiilt was pi rfi rt. 

Bawetion ol bone in aid of tendon-sntuie. It will siittit e merely td 
allude to this method, which ran otdy rarely be justifiable. K. Lobkcr' 
seems to have heeii the first to make ii.>*<' of it. In a case of long-standing 
(livi.sioii (if the teiiiliitis aiiiive tlie wrist. iiKititiiis of the radius and ulnar 
were resected. Tlie result was only a ]iattial success, and tlie lioties to(>i< 
three months to unite firmly. Mr. K. F. liuwlatnls has used this method 
most Hucceasfully.* 


This inav be occasionally called for in 8t)nie cases of acquired talipes 
calcaneus, where tiic tciido acliillis is elongated. As these cases ate 
« Centr.f. Chir., 1884, No. 50. * Lanct l, Oct. 21, 1905. 


;ijiuiillv till'' to iiifiintilf paralysis a rarcful cxiimiimtion of tho cli't'trical 
K-iK'tioii of till' culf lllll^M■l(>s hIioiiIiI Im> iiiatie before the operation. When 
iIm'so n«wrl«n» arc rornplftcly paralyHtnl and have undergone fatty 
. iM iafion. sliortoiiinu of tht' tfiido acliillirt is uhi'Ic»w. ('onviTBclv. if tin- 
. Ii 1 liii iil fxaiiiiimfion sho\v^4 that tlnTc is sonio hoaltliy inu8rletiiMU(> left, 
,t i> Wi ll to |>(>st|Mnic fhc .H|i(.itt'iiiiiv;of the tciidoii till ah much tunnl an 
iM.oililf has l)i'fii (ihtaiiK'il l)y a sysfciiiatic course of electrical treat- 
ii. nt. ( (iiiiliiiKMl with massa^'t' of the calf imMclen. In Huitable cases 
lite tciulo uchilliu uiuy be 8horteiie«l by one of the following methods : 

(I) WiUet't atthoi.' "A Y-shaped incision, some two inches in 
l.-ii'.'th. is made over the lower end of the tendo achillis down to the 
i.iidon. At the lower or vertical p)int of the iiicisioii the <li.s8ection 
I, (oiilimii'd until the tendon is fully e.\}Mwod over its suprficial and 
hi'i'ial surfaces for the space of one inch in lenjjtli, its deep connectitms 
liiinji left iiudirtturbed. The tendon is now cut across at the point 
III junction of the ol>li<|ne portion of the wound with the vertical. Next 
the proximal portion of the tendon is raised, with its suprfirial con- 
iiicfions to the intefpiment undisturbed, to the e.xteut of fullv three- 
liiarters of an inch, by diss««ctiu>r alonj; its upper surface, i.e. by re- 
\. i>iiii: the dissi'ction made ii|*on the distal sefjment. A wedfje-shapeil 
-liii' III the tendon is now cut oil from both segments, that from the 
|ii.i\irMM! Iiein^r removed from the deep .surface, whilst from the di.stal 
It Is taken from the superficial ; in both instances the face of the wedge- 
sliiipi il portion removed being at the point where the tendon has been 
liividcil. The heel being now pressed upwards, the pr'i.xinml portion. 
iii(iudini» both skin and tendon, is drawn down and placed over the 
ili-ial. thus l)nii;.'in;; )he prepared cut .surfaces of the tendon into apposi- 
;iiin. In this jHtsition they ari- held by an whilst 
Imiii siitiiies. two on either siile. are pa.ssed deepiv through 
til.' iiite}.'umeiit. then through both portions of the tendon, 
^iiiii again out through the integument, and fastened. 
When the uiN>ration is c(unpleted. the united edges of the 
vvdiind as.sume a V-shaped appearance, owing to the angle 
■ it the |)i.).\imal portion being now attached to the terminal 
|Miiiit lit the distal portion of the original incision." 

iL') Z-shaped method. This is described in (he oper- 
iitimis on the lower e.xtremitv. 

(i) Ollier's method of tendon shortening without 
terrupting its continuity.* When the tendon is lar 
removes with a very small kuife, the central part. A w • 
liiiviii!.' heiMi thus made, the upper and hiwer ends .e 
l>iiiii;.'lit together with sutures, and the lateral bands, folding 
ii|Hin either side, contribute to the joining of the two ends. 

W here the tendon is narrow, instead of making a 
uindow, M. Oilier adopts the plan shown in Fig. 47. 
Ill either case sutures of fine sterilLscd silk should 
St lengthen the .spot where the folded portions join the inain tendon. 


TO ns mpLOTmarr nr mAwnut pabaitiii 

It will be convenient to study here, owing to their a.ssociatioii with 
"|ii iations (ui tendmis, the surgical treatment of infantile paralysis, 

' lit. Uiirlholotiu w K HoipiUil Kfpnrli, vol, xvi. p. 309. 
Traili dea KiierliuH, vol. ii, p. 473. 



Fio. 47. 


.leveloumont. uiul when ut th.' san..' time the pa alvstrt n»'5'«» 

lis ■ C natrlv if .... .l-fM.ito plan is formulated, baaed on very .-are . 
: V . exLuiuation. Lny transpl.nUtH>n « ^^^ ^ ^ 
if the iioiHl ol ttnwmitting after-attention for long penods be lost 

Aslona ago as mi,.i ' rovoy,M a rase ..f paralytic talipe^ 
eautou:!;, Sic h he reinforced the tendo achilUs -^^^^^^^^^ ^I^Z 
with •> L'.....l H'siilt. Drobn k. of Posen, pubhshed "'V i 

i/. ..n"'. sixt...n in all. Dr. Milliken' and Dr. E. H- Bradford 

in this w..rk in America. In this country, first Mr R. J. Jones, oi 
Uv4r;o;rand. later. Mr. A. H. Tubhy. have tjjs method of 
troatment of a verv dish.'arteiuiin disease pn.nmi.M.tly tne pro 
"1 Medical Annual for 1^9 -"1 the 7 .v.y;W ^^^^^^^^^^^ 
('lnrnr<,in.l R. rl,-w 18W». p. 270. and more recently m their Surgtrv o 
p,,,,vs..s.- I'.H.:;. The cvdit of whatever P"^J" ^ J,y ' 

value i.i the account that follows be jiiven to these wnters especially. 


..BeforeitiM,Ki.le<lto,K.rfonntlK- o,Hrati.... th.- cum; 1..; '■''"•';'">;;♦"'';:;;': 
Bhouli be pri vioiislv awcrtiiincil. ana .ui aui ...pi ii.J<i< • Hccondan 

«. mH l sllv ,.arah . xhibit after the operation «gn8 .f tvUm « • J\'' 
I, nlrXln ls rarely- calUd for w»u-u only one «»«le U paralysed, nor shouUl .t In 

3 Av'r j'or*- Mrd. Hecord. Nov. 28. 1896. « Ann. oJS,rg.. Aug. 1897. 

» Tubby and Jones, p. 1159. 

Fill. 4H. Till' |K'n> 
iiriiM liint;ii.'< li'Milmi 
li II i> lir r M il r II w 11 
thriMiKh niiil lixril 
on to the back t4 
(hr ti>ndn •rhillk 
Tin- rnils of «lii' |HTii 
iifii" tfiiiliin i>" ■ WWII 
• III to till' Imr f till- 
ti'iiilii Ill-hill., at ii 
mill i:. havinu h<-i'n 
first ilrawn tkluuKb 
till' ti'iiilon at r. 
('I'lililiv iinil ' lilt s. I 


i.,iii «hi n m arly all the muiirlor muml a joint nro iiii|.liriiti il. Thr latter i niipn are 
uimIiIo only fur nrthrcMbitiM {i/.v., o|M'ratiiins on tin- lnvn r rxtn iiiity ). anil. inihi>il, 
; hiTi' lit a ffar that an iiMliacriminait um- of tniii»|iliintiitioti niuv Iriul ii> unMtiiHdu'lory 
. suHa. awi M Mug Uw <venliaii iMo MmlMmrMl diMmitt'. A gnwt mini to ike 
liiiirrol eWM. 

The idectMl mttadp nhoukl U-kmg. if ptMMibfe, to the a*iiie gnMip aa the iMnlvanl 
,iM-, hrraoMi tt b m-anut, attil rmtoration of volnntary funrlion In thiw mon- qui'ckly 
mI iKrfifflv aecurcd. "The rvinforrinK tinilim shoiilil Im- 
Mini a» directly aa |ioHHible to the imralvwHl miisilf. and 
.1 Ill-lit round at an an)(le. a inaniiMivn- whirli has tlii-i-ili-rt of 
.ii.iili'rahly liuM'niiiR tlir transfer of |Kiwi-r. For inst.inrc. 
ii iIm- (M'niiu'UH liri'vis wrrc iiwd to ri i.ifiirri- tin- i xli-ii.-.iir 
. .iiiiiiiiiiis ili)(iloruin. tin- foriiirr should In- iittarlinl to tin- 
I iiii r iiIkivc the nnkly. and not Ih-Iow and in fnint of tin- v\- 
iiTiial inalleolilM. Wlien an o|i|Mini<iit of a |iiiriily.>.ril miisi |c 

lii tMl, it givea emiihaMia to thix |iriiui|ilr, iiamt lv. that 

l.\ ~i lirtii^f one of the opponenta ol a |mnilyitetl miisi li- wi> 
h.ii Hilly mnforee that weak mumble, hut we IcHM-n the mi- 
..iiiiis.ii whii h exists U-lween the twiiKroii|iN. And by truiui- 
■. iiiiiii. fiirexani|ile. the inwrtion of the )M'rnneuH longUM in u 
of |iiiralytie tali|>eH val)(ii.i from the outer to th«' inwr 
l...rileriif the f(H)t, we etfeet an e(|iialitv lietween the foreea 
.iitiiiji U|Hm th«< two Uinh'rs." Mr. fiihliv ' mentions the 
following method* of tendon-trans|ilantatiori : 

.1. Intrrmidinte MithiKls. ||) The 
tenilon of a iiealtliy iiiiisele i> i'iim|iletelv 
l ilt aiTosN near its iH>ri|iheMl extremity, 
mid it.s eeiitral end is inserted into the 
|iaralyi«-<l timdon (Figs. 4H and 411). 

(•2) Tlic central end of the divided 
healthy tendon i« attached to a Htrip from the distal iiarl of the 
imralyMed tendon. 

(3) The healthy and tht |iaralyiied tendons are divided, 
the een«ral end of the active one in joiniKl fo the diHtnlend of 

t <" paralyHed, and the |ir — ' ' • - ■■ 

to the (liHtal end of the 
lerrhailKe " inethiHl. 

(4) The paralysed tendon is i ut aerosM, and its distal end 
IS sutured to that of a healthy mu.sele. 

(.">) A strip is taken from' the central part of a healthy 
tendon, and is attached difectly to the imdiirided pamlyaed 
tendon ( Fijts. .'il and .12). 

(«) A strip from the ei ntral part of the healthv tendon is 
joinetl tou Htripfroni the distal part of tin- paralysed tendon. 
This method givea lM tt< r results tiian hIIh is'. Iiecause the 

continuity of the healthy tendon is not desnovi d • pletelv. 

and Its uvtkm ia folly comerved. Moreover, as the continuit v 
of the (Miralysed tendon is not interrupted, if som<- rei over'v 
takes jilaee later in the npimrently paralysed nius.le, or if 
miy power remains in it. aid is given to the reinforcing .striii 
from the healthy tendon. 

«. The Immdiiil, Mtth,„i. Here the heulthv tendon is 
divided and is then directly attached to the |M'ri<>sfeum. 

This method has Ih-cii strongly advocated hy f.ange. of 
Munich, whoaserilx s many of the failures in tendon-grafting 
to suhseipu nt stretching of the paralysed and degem-rated ten- 
don.-' Where the di.-taiice betwcea the sound tendon and 
Its new insertion is tcHi great, tlii.s .surgeon eniploys artificial 
tendons of silk (Fig. .5(1). He reports fifty six lases. In only 
two wa.s the result iiiisatisfacfoiy. In a of paralysis df 
. , .. , ^ «l«»driceps extensor, where attempts to corn et the de- 

^^Z^T^f "tl'""^^ ^ ^"K*-- «>.'i tendinosus 

I ; u-I' n T"* the skm. after fm-ing then, from their insertion.s. The 
1 1 Mil, wen. now found to so far abore the patella that it was impoaaible to mtuie 
liiformttiet. vol. ii, p. 626. 

|m 145"" ' ' ■^P"' ««» Jtferf. ibeonf, voL r, No. 3. pp. 

active one m joiniKl fo the diHtnlend of 
proximal «ndof the iiaralyHediH joined 
he nctiv Thia i» the -*compk>te in- 

Ki.:. 4!l. Teniliin- 
'jMftiiiL' for relief of 
|iir ilvtii- tali|ies cal- 
iM 11^ hy insertion of 
III. |iiriiiieiis loiidus 
i.iliiii II into the 
i tniilii achillls at h. 
■At (• isseentheilistal 
III I if the peroneuN 
liiiiL'ii^. (Tubby and 




tbem to the ligamentum pattlte. A servic-abU- silk t. mU.ii was<l. <l |.y tl.r 
vmmgB ot a anmber of silk threads through tli.- t. ii.liiu.iw . luU of I ..■ tnms- 
IwmgB w . uuu ,,|,int,.il muscles uImivc, mill the [x n 

ostcuin of the tulKTcle of the tiliia 
below, tsiviug eventually exeelleiil 
])Ower of exti'iision. Several of thf 
^. 1 -v X . artiticial teiuioiiH wer» eight inchcH 

uweps -|- \ / >i |„„g_ When, some montha after the 

o|H-ratioii, the tranaplanted mttacles 
Ix gaii to act. and render the silk eonb constantly 
light, these steadily increased in thickness. It is 
probable that the increase in size was <liu^ to the 
formation of fibrous tissui- around tlie silk. 

Of this nu tliml .Mr. Tubby says : " There is no 
doubt that the ininu diate method of JJinge marks 
a great advance over tlie older methods and has 
ra|>i(llv displaced them." 

Hci'ore the i)|MTatii)n all secondary dcforinilies. 
such as contraelion of fasi ia'. must be remedied. 
The im|>oitancc of electrically testing the museh-s 
has alreaily been emphasised." fare must b«- taken 
to si lei t such teiulons as will improve function 
liminish deformity. Mr. Tubby in-ists on 

Flo. r>0. Ijinge's method of 
artiiieially eloniialing the tran-* 
planted hanistrinjitendiiiis liy sUk 
suture.', sii as tiictfcc t a juiii t inn 
with the tulxTtle of the tibia. 
(Tubby and Jones, after Liinge). 

ployed in tlu' stationary stage 

the necessity of a clear con- 
cept ion of the relative import- 
ance of the functions of the 
jMirt. He also (H)ints out that 
the o|)eration should Ik- em- 

, <)f infantile )Kindysis when it 

IS quite certain that the trouble is otherwise irreUM-diable. 

Technuiue «/ tin (li>i ralinn. Needless to say the most <'areful 
lireeantions nnist Im- taken to avoid sepsis. "In many case-* 
a single incision will sntlici'. but it sonietimcs hapi«'"s that, to 
avoid a single lart;i- incision, two sinallcr ones aie made, < .(/. 
when the pcroMi ii> Imigus is transfi ricd to the inner bonier of 
the foot. In this one incision is ma<leovi. r the froi\t of the 
tibvda. and a second over the seuphoid.' By burrowing through 
the suU'utancous tissues of the dorsum of the foot with a 
director, a channel is made for the passa^'e of the tendon to the 
scaphoid. It is curious to remark that no adhesion of the 
transplanted tendon fakes place to the subcutaneous tissue 
doubtless from the endothelium on its surface: hence we 
learn the necessity of handling the tendons very carefully." 
As regards the actual mctluMi to Im' adopted .Mr. Tubby re- 
marks: "If we the intermediate nielhod, it is generally 
conceded that the best results have been obtained by one of 
two procedures. Fit her joining a strip of the reinforcing tendon 
to one taken from thi'<l one. or. better still, laying the 
strips side by side and tirmly uniting tliciii. riidoulitcdly. 
however, the most reliable results arc reached by l.iinges 
direct ]H riosteal implantation."- (ireat care must Ije taken to 
avoid anv twisting of the tendon or bending it at an angle. 
Mr. Tubby advises that sterilisable electrodes shouM be at 
hand in case it should be thought necessary to ascertain the 
condition «rf the muscles. This may also be determined by 
)•• -icction. " Thus a lu-althy iniiscle is dark red. and its tendon 
' istening white ; a paralysed muscle and temlon are yellow- 
w.iite. a ])artially paralyseci niusele is mottled, red and yellow. 

1 Needless incisions for ex|)lorati(in slioidd be avoided. These cases. Imii: the subjitli 
of trophic lesions, are not ideal ones for si-ciirintt priinnry union. Further, any incisions 
required should not be too lonj; ; the scars are undoubtedly liable to become keloid, ft 
result which may interfere with the aftcr-trr.ilnii'ut, anil the pressure of boots. 

^ \\ hen LUnVe's method is eiiiployeil. the silk for artificial tenduiis should be pn-partnl 
us follows : " 'i'he skeiu of silk is undone and Hoaked fur half an hour in ether, and then 
for a few minutes in alcohol. It is then boiled for one hour and pkced for a week in a 
solution of 1 in lUUU biniodidu of mercury. It is finally wound on glass reeb and always 
kept fat thto adntkm.' ' 

Flii. .'il. ()|M'ration 
for relief of paralyti' 
tali|M's eipiiiiO'Val 
giis. The inner |utrl 
of the gastriM'neniiii'* 
andteudoachillis i~ 
split iitf at II, II, aiiil 
divided at 6. (Tubbv 
and Jones.) 


th.- tendon in whit^ The last-named muHclen will respoml ,mrllv („ H,i,„„|i 

t MX «.vks .1. phish r „f I'arm. The gr.-att*t danger «rf nbitme mlrt^ tkut 

I. „ olf. M, that smtiil.l.. su|.,K,rtH Hhould \mi employtS fcoth 
nitrlit and (liiy t<i limit the inovemcntN. And here no 
, .1 lilies lail !«• Kivrii; cxiHTicucc ii|,mo is useful. Move- 
III- iiiiist !«• liiiiitrd iit first, and then ver>' uraduiilly in- 
: ,,Hd. The nutrition of the of the transnlaiil,.,! 
• rMliiii should Ix' iiiaiiitiiined at its highest iMiint l>v vrrv 
, .n fiil niuHHagu-. ami by Wf»k electric ciirrciits. and cirort's 
I. made to n--e<lueiite the traiiHj.lunt.-d muscle and tendon 
;.i Ihcir new function." 

Details of the various r)pprati(>ii.s will bo found in 
I 111- (iesciiption of the operative treatment of the 
ililTereiit forms of talipes in vol. ii. 

Infanlile Sjiaxtir J'aralifHis. or Cnhrot l'm„l,,.si<, „f Chil- 
■ln„.' The two authors from whom the alK)vo quotations 
li .v. Ikcii inadcKrouptheireascsinto(l)iiifuntilehemi|.hKia • 
IL') .. rchral diph.gia ; {'.i) silastic |Mindy«i«. In ccrchral 
.|i|.l. -,;,. uhlic ripdily and iiaralysis arc aasociatwl. rigidity 
K III. iiini, >ii,lunn f.aturc : in the hemiplegie fonn iiaralysi^ 
londcratcs, the rigidity hciiia si-cmdary to it. Again, in 
the hcniiplcKic form, the arm' in 
more affected than the h.g, Imt this 
IS not so with the diplcgic form. 

The fo||„wiiin facts are of chief 
interest to the- surgeon: (a) The 
U|.|« r linih, when airected, is more 
seriously im|.licated than the lower. 
(/>) The lesion of the iip|M r liml> is 
more iiermanent. (, ) Th,. |H,wer of 
dorsi-flexion of the han<l and the 
Kinuiltaneoiiti extenHion of the fingers 
IS lost, (rf) The moveinents are 
P'-rforiiH-d without precision, siias- 
niodically and .slowly. (^) The 
|>ower of the thumb is often lout. 

The disabilitieH of the lower 
limb are generally: (a) Contraction 

""■ ><> • ('') Kxtension of the 

foot. (.) Int.rnal rotation of the 
fcniiir. with adduction. (,/) Higidity. 

The cerebral iliplcgic form is I'ly 
far the most .serious, as we have to 
deal here with Inith arms and legs 

ZZ^' ''"""^ "iti'-H't «'ven 

S t JJTl'' r''?'^ <'""'PI« <- .....I liaitial dis. 
ability (rf the hands, (r) Complete and partial disahilitv 

I J 



II l..r thi- n iief of 
- v.iL'iK. The |M ro 
I'll \ I-. ((. Is divided 

Flo. .'■.2. The st cond 
sta^'i.iiflhco|ie ration 
for the relief of |>nra- 
lylic talijH.s ci|iiino- 
valiiiis. 'I'hc inner 
half of the gaslriK'- 
nemiiis and tendo 
nehilliM n is hmiight 
forward and nnitcil 
cither to the tiliialis 
post iciis/j. orthe|«Ti 
osiciini of the SI a 
conHistM in division uf 
the outer half of the 
tendo ai'hillisinorder 
ton lievi tliei i,iiinus. 
(Tiililiy anil .loiics.) 

Clinically this group 

in-iiliil into th 
iil'i.ili- Hiitii iis. r. at I . At 
I- -" II the ilKial end of 
Hm- |H'ioneiis liievis. and h 
mat ks t he iHToneiis lonuiis. 
(Tiililiy anil .lones.) 

(rf) Cases uNsiKiated with athetotic 


of the limiw. 


to tt J.I""''!'''"^.'"*' c^ast^ which a«. and are not adapted 
lo ticaf mcjt - A suitable ca«e for tn atmcnt is a <f|iild 
.y...."K adult of fair intelk^-tual development, who l a 
I 'd no tits for hre,. or four yeam. tiuci a case may be 

-- "f .ali.s.s e,uinu.s':r ir 'ai ' t 'Kt^'Zied'''^" 

•I- ... tins hitherto mc»t Jp^^Z^^ ^'Za^':^''X'" f t '"'"T'tr 
thi, account inured. '^"""l"*''' »«> Tubby s //./orwKie* (1912) from whicfc 


dnotion <rf the thighs. The thighs are flexed and inverted, and the tensor fasci.-e 
fcmoris. sartorius, and ilio-tibial band are rigidiy contracted. 

B. The classes of cases which are entirely nnsuited for treatment ar.> the idiotic. 
th> microcephalic and the violently irritable diplegie who is subject to Hfs, active 
athetotic iiiovementu and loiivulsioiis. ami the patient who has no control over the 
sphincters. Another class of case which i i;ot !io|H>fnl for treatment is where the 
affection of flie hands is of such a cliaracuT as to promise lint sli>;ht lio|ie of their 
OMsistance to the lower limln during walking with crutches. That is to say, if th«' 
piiralysis is complete, or if spasm of the hand and arm never i^hixes, treatment is 
of little avail. 

It is important to recognise llic length of treatment reipiiretl. Active Invitmcnl 
may be required for many months, and it is therefore unwise to undertake a casi' in 
the hospital for a month or two. and then to »enil it to a miserable lionu\ where 
neglect will be the inevitable consequence. Even after active treatment has ceased, 
massage, skilfully directed exercises, with careful and thorough eilucation of the 
muscles in acquiring new movements, must be carried out for some years. It is 
therefore nwcssary to secure the co-o|NTatlon of intelligent 
j)nrent.s, anxiims to rio all they can for their child and 
wiHing to face all the trouble involved in careful training. 

The principles ujKm which o|H-rative treatment is ad- 
vised are as follows: (I) A constantly overstretched |Kira- 
lysed muscle tends to bcc(inic progressivi^ly weak and 
degenerate. By tc^notoiTiy they are placed in a state of 
rest and may then recover. (2) Kxccssive deep rctlexcs 
are characteri.stic of thii- disease ; it is therefore of the 
greatest importance, if |MM«tible. to limit this excituliilit y. 
Tlie tension of a muscle is retlexly de|H'ndcnt upon the 
tension of its tendon. If the tendon fA a tightly con- 
tracted muscle is divided, the stimidi which it sends to the 
cord, and which are thence reflected to the muscles, abate. 
The vicious circle is thus broken, and the muscle is no 
longer tonically contracted. 

Thus, in spastic taliiK-s e<piinus. division of the tendo 
achillis will enable the pointed condition of tlief<H>t to be 
remedied, and prevent over stretching of the paretic ex- 
tensors wliii li are in this way placed in a slate of rest and 
therefore in a [losition of recovery. Again by division of 
the tendo achillis. the rc llcx c xcilalijlity of the < alf muscles 
has been largely abolished ; and not" only so, but the 
authors believe that the removal of this exei'ssive rcHex 
excitability of the cord permits of that quiescence of the 
nerve centres so essential to the welfare of these children. 

Trealment. This falls into the following divisions : A. Operative and B. post- 
operative. ( I ) Treatment of the upper extremities ; (2) Tn-atment in the caw of the 
lower extremities. 

(1) Trenlmeiil in thf cast' of the iiijptr trlrcmitirn. The most pronoiuieed 
deformities here aretlexion of the cIIhiw. pronation of the forearm, and Hexion of the 
wrist and fingers. The o|H'ralive procedures consist of tenotomy, tendon trans- 
plantation, and h'ugtliening of tendons. In all lases it is best "to commence by 
relieving the spasm of the ticxor tendons at the wrist, remi inbering I hut in spastic 
conditions there is <langer of over-correction. .Mr. Tnliby recommends (</) h'ngthen- 
ing the tendons of the flexor sublimis and profundus nt the wrist hy the X-method. 
(6) In order to overcome upasm of the carpal flexors, transplantation i)f the 
flexor carp radialia and the flexor caqii ulnaris to the dorsal surface of the bases 
of the second and fifth metacarpals, as originally suggesteil by .Mr. H. .lones. 
When the tendons are not long enough. IJingc's method of prol(M^[ing them by 
strands of silk may be employed. Great care must be taken to avoid matting of 
tendons or much stilfness may result. To relieve the flexion of the elbow ond ex- 
cessive pronation of tUr forearm .Mr. Tubby describes an o]H'ration for converting 
the pronator radii teres into a supinator by transplanting its tendon behind the 
laiiiu'i. through an incision in the interosseous membrane, to the outer side of the 
radius. ' 

Till u fttr-truUmi lit consists in educating atid training the limb in its new 
' This operation is descrilied by Mr. Tubby in the Itril. Med. Johth., Sept. 7, 1901, and 
with severM imfiortaBt modiflcattons, in Defirmitiet (1018), vol. ii. p. 720. 

Kiii. .">4. Transplantation 
of the sartorius into i\v 
patella at u tu n>inforce 
a paralysed quadriceps. 
The distal paxl of the 
divided sartorius is seen 
at&. (Tubby and Junes.) 



jKinitioiL Passive movpmpnts are at first limited, so as not to stretch the bonds 
uf union unduly. .in:\ .-iftcr the sixth week they are more extensive. At the 
liitter date active iiioveint'iit.s are begun. The principles whieh should guide 
them are as folio a : {m The move:iiei\ts stioul 1 l)u pra t se I slonly without 
e xcitement, {h) 'Chry sliould lie mtili' iiitiTcstin^ to the patient, (r) 
niovemeiitH whic' arc opposed lo ilic direction of the deformity should predoini- 
ii.itc. ('/) Tho prcsciitiiifi the greatest dilKciilty sliould he chicHy practis<'d. 

(1' ) TiHiiiiii III ill till cfl-r of till Idirirtxtn tiiitim. The following si^ries of o{HTations 
11 the hip. knee, and ankle may he rei|uircd. and ar.> \kt- 
i iiincd. if necessary, in stau'-*. <)|K n o|H'ration is always 
iiiilicated. The achlnctors uf the thinh are lirst dealt 
with. The adductor longiis is e-XjiosiKl through a longi- 
I udinal incision and three-quarters of an inch of its tendon 
IS excised. The limb i» nbdncted and the adductor brevis 
and the gmrilis are tri'ated in the mime way. If needful, 
the horizontal iiart of the adductor magnUH and the pee- 
lincus are divided: in fact, everj' tissue which limits fn-e 
liidiiction ; the sartorins. tensor fascifB femoris, and ilio- 
iil'ial liaml are divided in the same way. The knee is then 
dealt with liy lotiffitiidiiial incisions, one on either siiK- 
iiMiall\ snftiiini;. liy liurrowing iiudi-r thi' snhcutancous 
lissiie. and rctractiiiii the skin, the various hands of fascia 
rill he reached and divided as well as the haiiistrini!s. 
Tinally the tendo acliillis is el()iij;atcd liy the Z method 
l /.c.) and the patient is then secured comfortalily in .loues's 
.iluhiction fraine with the knees straight and the feet at 
light aiigUs. At the end of thre(> months the splint is 
taken off during the day and the movements arc regularly 
practised. A little later, when the |)atient has Wn taught 
to stand unHup|H)rted, walking is begun w ith eniti hes. At 
lirst the inirsi' must t.ike gri'at <'are that tlii- limhs are 
not appro.\lmatcd. 'I'hc limhs nnist he kept ahdiictetl at 
night, and massage of the muscles, with active and (lassivo 
iiiovenients of the dilVcrcnt joints and addnctioe of the 
liinlis must lie assiduously practised. In from twelve lo 
iHciity-foiir n iiiths, with careful siipci vision and aftcr- 
tn atmcnt. and with the intelligent < n (ipciatioii of the 
pii'ciils, the child sh'>iild Ih' able to walk a consldcialile 
distance, aided by sticks, and this with perfectly straight 
limits, and toes and heels on the ground. Later on. 
many eases will manage to walk with one stick only, and 
others will be able to dls|><' with all kinds of urtitieial 

The conchisions of .Messrs. Tubby ai«l .lones have been 
i:iveii at length lie/.iiise of the pains which they have taken 
iiidcvelop the dilfcient o|M'ratioiis and the authority with 
« hich thi'V speak upon orthopa'dic siihjei ts. Hut it is right 
111 state that lh<>re is another siile to this ipiestioii. and 
lliil other (ipiiiioMs ate less favoiiialile. In this country 
neither .Mr. Ki'etlcy ii'ir .Mr. .larkson Clarke speaks highly 
ol the result in tlicir hooks on > hHinjiiiilii Siiiyiri/. And 
It musf ' remiMiilicied that both are men of large ex- 
pcriei and well known fairness. 

From .\meriea, where every fresh operation is at once 
tested largely and with much zest, we nave warnings not 
to expect too miieli from tendon-transplantation in infantile paralysis. 

Thus Dr. Hibi)s, sjteiking i»t a nuH'ting of the New York Academy of .Mt^lieine, 
from an exiM'rience of 150 cases ojKrated on at the .New York Orthopedic HoM|Htat 
said : " Where sufficient time is allowed to ela|).se, the ultimate compared with the 
immediate results are as a rule very dlsa|i|iointing. In itself tendon-transplantation 
practically never fullils e\pectation. and is only a help to the use of apparatus. It 
is not an independent orthopedic measure ; it does not prevent deformity, but 
may he used as all adjunct lo facilitate the iim' of apparatus, and thus enalile tho 
rthop.edie surgeon to use any (xissible bit of force which the |>atient ean exert. 
Tho opcntion imdoubtedly deierves » place in tho araamcntuium «^ the ortitopwdio 

Kiii.-'ri. Mils h'-tr-ins. 
pUiit ition for tlie ndief 
of! iprelriceps 
hy rciiiforrciiieiit of the 
piralyscd mu.selo from 
.At II a slip is brought 
f o r w a r tl . f r o m tjj e 
biceps; at 'i the proxi- 
mal part of the sar- 
tniiii^ is l)rr>ut;)it for- 
ward and the muscular 
slips a and h are in- 
.sertod into tho patella 
at t. The ilistiil i>or- 
lioiis of the hic<>ps and 
sarliiriiis arc slmwii at 
(/ and r. If tlw sar- 
foriiis 1k' paralysed, the 
HumitondinoHUs may ho 
used instead. (Tiibby 
and Jones.) 


AUtgfon, but hail nothing hkc the niHrvclloiis rtTect whieli is Nniiictiiiit's i laiiiu'd 
for it." ' 

Later opinkMU are, however, mote favourable. Thus Dr. R. \V. l^vett. of 
Boston (Sixteenth International Congtera of Medicine, section 7, p. 13), myf, " In 
some iiMtance* the rcHults are brilliant, in some the extent and chamcler of the 
paralysis prevent us from obtaining as good functional results an we woiihl desire. 
We know of no case in our series made worse by t>perBtion. Under these <-oiiditionH 
we now regard the operaticm in suilabi!/ seleete'd easts as one stmnglv to lie reeoiii- 
iiieiided to pntientH and in the great majorty of such caseo as one uJlowed by mont 
satisfactory resultH." 

The method must therefore be still repurdi il as siih juilicr. \\\ will 
allow that the results of treatment of irifanti paralysis aie anionjxst 
the least creditable to jis. If teiidoii-traii.s| utatioii does no hkhc 
it may at least do good by attractiiifi. with its fjlaiiioiir of a new opeta- 
tioii. more attention to a neglected subject. Whether the results claimed 
by some are verified in the future depends not so much on jierfection 
of technique— already largely arriveil at as on a wise selection iit 
cases, more careful attention to after-treatmetit. in wliicli the jiatient 
and friends share a larger responsibility, and. above all. to ni( <li< :il 
nten ceasing to look upon as ones in wliicli nothing can 
be done and aUoning them to drift on until, early childhood past, 
the mi.schief is advanced and confirmed, and not <;nly the tendons 
to which too much attention has been directed but the ligaments, 
joints, bones, fascise. and skin are all concerned. Finally the liteiatiiie 
of this subject, which has rapidly increased, would gain greatly in value 
if those reporting of operati(m would do so in more detail and 
with greater accuracy, and also woidd give us the later as well as the 
earlier results, telling us especially how far tendon-transiilantation 
does away with that worst of all sequelie of infantile jjaralysis, viz. 
the trophic ulceration, which is so liable to set in in late adolescence 
and early adult life, and which may call for amputation of the thigh. 

» J/(rf.A<ic.», April 12, l!H»2. 




This operation is not often performed. Extensive tuberculous disease, 
with abscesses and sinuses, is practically the only indication. Tlio 
conditions needful for success and the reasons for it often fiiiiinfi may 
tir«t be considered. 

(1) Whether tlie tuberculou.sdi.sease be<;ins in tlie .synovial membrane 
or in the bones it extends rapidly, not only to the wrist joint, but to 
the two rows of carpal bones and the bases of the metacarpals, along 
the complicated synovia! membranes,* which bring all these bones 
into contiguity with each other. The disease tlui.s e.xten.sivc. i.s 
most obstinate, and is often further complicated by other tiilicrcuiou.s 
Icsion.s. and. in adult.s especially, by a tendency to })litliisis. Tlni.s 
partial operations are useless and often worse than useless. Lord Lister - 
was the first to insist on the importance, and to show the po.ssibility, 
of removing every trace of the disease, including the ends of the radiiia 
and ulna, the two rows of carpal bones, and the bases of the meta- 
carpals (Fig, 5S). 

(2) From the close relation of the flexor and extensor tendons in front 
and behind these complicated joints, ami fiom the iiurnerons ;;rooves 
on *lie bones, it is most difficult to extirpate tlie disease without dis- 
turoing the tendons. The tendon-sheaths too may be extensively 
invaded by the disease. However stiif the wrist may be left, flexion 
and extension of the fingers are absolutely needful for the operation to 
be a success ; hence it is imperative that, thronphout the prolonged 
operation, the t" s slK)uld he disturbed as little as possil)!(', a direction 
very <liili('ult ' w, since the slieaths are fre(|uently tulx-nnlous, 
and the necess. .anipulations uig the operation may easily lead 
to the tendons sluuguing, a»id thus to a useless tin-like " hand. 

(3) Passive movement of the fingers should be begun as early as 

' 'I'lic i\rr»iii.'<'iiu'nt of tht'sp, iixiially Kvc in numlxT. must In? iviiicmlicri'd, :iiicl llicir 
I Icisi' proximity to cuh other. («) Tlio nu'inlinina MU cKorniis of tlic inferior railio- 
ulnar joint, which also lines the un|)er »urfaee of the triangular tibio-eartilage. (/i) That 
of tho wrist-joint proper, pasfting from the lower end of the radius And the inter artieular 
fibm-rartila)ic above to the bones of the first row below, (r) The common synovial 
membrane of the carpus, the most complex of all, extending transversely between tho 
hones of the two rows atid sending upwards two vertical prolongations Ix'tween tho 
M a|ilioid and tlu' semi-lunar and the scnii-hmar and cuneiform, and downwards three 
prolrMiL'ations l.'ctwccn the four hones of the .s!". onil row iisually. h:;! !;o! alwav ; ; :ii)!miir.i- 
cating with the inner four carpo-mctiicarpal joints, (rf) A separate mem hrano for the 
joint between the pisiform and the cuneiform, (c) Another separate one between tho 
trapezium and the Hr»t metararpal. Fijj. 56 shows a variety of this arrangement in which 
icven synovial sacs are present. 

* Lanftt. vol. i, p. 308. 



possible, and most piTscverinjily nmintained. Owing to the unsatis- 
factory cliaiactiT whit li tliis operation inherited by the very poor results 
to which it attained before the days of aseptic surgery, and owing to 
the unsatisfactory condititHU, both general and local, with which the 

surgeon is called upon 
to deal — the estab- 
lished tuberculous 
trouble, often not iso- 
lated in the wrist- 
joint, the joint itself 
and tendons, it may 
be, riddled with 
sinuses, and the 
fingers swollen and 
stiff — excision of the 
wrist has not found 
the favour with Eng- 
lish surgeons which it 
perhaps deserves. 

In spite of the 
above disadvantages 
and difficulties, it is 
iiUK'h to be desired 
that, as no less than 
the saving of hand 
and fingers is at stake, 
this operation should, 
with the advantages 
of modern surgery, 
be persevered with, 
and that all cases, whatever the result, be fully published. 

Two methods only will be dcsciibeil. E.xrision of the wrist is not 
a common operation ; it must be a difficult one ; and the operating 
surgeon will do well to make himself familiar with, and to practise, one - 
method. The two methods fiWcu below bear the names of sui^^ns 
who are authorities on the subject (1) Lord Lister's, introduced to the 
profession as long a>zo as 11^05; (2) that of the late M. Oilier, whose 
name stands second to none as an authority on e.xcision of joints, and 
who has done more than any other surgeon to place excision of the 
wrist on a sound basis. The second method may be recommended as 
the less complicated of the two. In young children, owing to the 
weakness of the 'ir;ainentous and other fibrous single structures, the 
single longitudinal dorsal incision of van Langenbeck or Boeckel— for 
they are practically the same — may suffice. 

(1) U^'S OMrattOD (Fig8. 57, 68). In this method two inoiakms are 
rei^uiml, one on tne radial side of the donum, the other on the inner ride of the 
wrist. Bi'forc the oi)oration the fingers are forcibly moved so as to break down any 
adhesions. An Esmurcli's biiiulagu or tourniquet should be employed. The 
radial incitsion. angular in direction, is tlii'rt made, as in Fig. .57. This incision is 
pjanni'd so as to avoitl the radial artery and also the tendons of the exten.sor seeundi 
internodii and extcn-ior indicis. It commences above at the middle of the dorsjU asjK'Ct 
of the radius on a Icvi l with tlu> styloid process. Thence it is at tirst directed towards 
the inner side of the metacarpo-phalangeul joint of the thumb, running parallel 
in this course to the extensor seeundi internodii ; but on reaching the lioe of the 

Flo. •"•<>. The Iwini's am! the seven synnvial sacs which 
enter iiilii jiiiiits iil)ciiil the wrist. The seviril h. that Inlwcen 
the ciincifdrni and |ii>ifiirin, is nut shown. (.Mai ( 'orniac. ) 


M<lial Ixirilor of tliu sfcoitil inctai'ariiat Ixiiii'. it is rarrii il dciwiiWiiiilit loii^ihiiliiially 
for hulf itx k-nstli, tin- ruilinl artery Ix-ins tliuit ti voided, am it Iii-m n little further out. 
Tho tendon of tne extensor rnrpi radinllH longior in next «k'tach«l, tnoether with 
that of the ( Nti ii-ior lircvior, while tho extensor h^undi intemodii. with the mdiiil 
artery, in thrust sonuwliat outwanls. The next Htep is the Kepiiration of tlw 
tnilieziiiin froni tho I'l'st of the carpiis l>y eutting foree|(» applicil in a line with the 
longitudinal part of tlir iiu-isioii, unvit care In-ing taken of tlm radial artery. Tho 
removal of tlu? trapi/.iiiiii is li ft till the nst of the eurpiis has liecii taken away, 
wlicii it (ail I • (lisscctod out without miicli ditlieulty, when as its intiniate relations 
with tlic artery aii<l iieinhlioiiriii;; parts would i'ause luucli trouhle at an earliiT 
.-I i;;e. The hand heing heiit hack to relax the extensors, thi' ulnar iueision sliould 
ue.xt he made very frei' hy t'ntering the knife at least fwo implies almve the end of 

Fl(i. .">:. 

secUMili iiil 

. Kadial 
iiiidii pol 

FUi. .">8. Parts removed in excision 
of the wrist. (Lister.) 

ieis. ( . Kxterisiir indie is. 
n. Kxleusi.i oiiiiiuiuis. K. Kxteiisor minimi 
(liu'iti. r. K.xtensor primi internoilii. i;, Kx- 
tensiir ossis metacarpi. H, Extensor earpi 
radialis lon^tior. i, Kxtensor carpi radialis 
ha'vior. k. K.xtenaor carpi ulnaris. i. h. Lino 
of radial incision. (Ustcr.) 

the ulna immediately anterior to the bone, and carrying it down between the bone 
an<l the flexor carpi ulnaris, and on in a straight lino as far as the middle of the fifth 
metacarpal bone at its palmar aspect. Tho dorsal lip of tho incision is then raised, 
and the tendon of the e;;tensor carpi uhiar is cut at its insertion, and its tendon 
dissected up from its groove in the ulna, care being taken not to i.solate it from tho 
integuineiit.s, which would endanger its vitality. The linger extensors are then sepa- 
rated from the carpus, and tlip dorsal and internal lateral ligaments of tho wrist-joint 
divided, hut the connections of the tendons with the. radius are puriMJsely left un- 
disturbed. Attention is now directed to the palmar side of the incision. Tho 
anterior surface of the ulna is cleared liy cutting towards^the bone so as to avoid 
the artery and nerve, tho articulation of tho pisiform bono opened, if that ha-s not 
.dready been done in making tho incision, and tho lloxor tendons separated from 
tlie carpus, the hand being tloprcs.sed to relax them. While this is being done, the 
knife is arrested by tho mieiform |)rocoss. •.vhieli is clipped through at it bast with lionc- 
forccps. ("are is taken to avoid carrying tho knife further down tho hand than tho 
bases of tho metacarpal bones, for tliis, besides inflicting unnecessary injuiy, would 
involve risk of cutting the deep palmar arch. The anterior ligament of the wrwt- 
joint is a,\ao divided, after which the junction between carpus and metacarpua is 
severed with eutting forcefw. and the carpus is extracted from the tilnar incision 
with scquestruni-forceiw, any ligamentous connections being divided with the knife. 
Tho hand being now forcibly everted, the articular ends ol the radius and ulna 
will protrude at the ulnar incision. If ttey appear aound, or very superficially 
effacted, the articular surfaces only are removed. The ulna is divided obliquely 


a Hiiiall hiiw. Hii as to lake away tlii' nirtila);<'-<'<>vi'i'('<l riiiiinlcil pari om i- wIik Ii 
ihi' radiuM Hwti'liH, wliilc tlir liasc of llir styloid [iriKTMi* is n taim il. 'I'Ih- ulna and 
nuliiiN an- thiw left of the hiuiu' li'iigtli, which Krcutly iiroiiiotcs tlx- Hyiiiiiictiy and 
Ktvtulinnw of tht> hand, the anguiiir interval betwepn the Immhh UttngMion Mkd u\t 
with fmth ofwif^c dc'iioait. A tnin idicc in then wmi oil the radiiw pantlk'l with the 
artiruliir Hiirfaci'. 

For this it is scaret'ly neocmiary to diHturb the tondom in their groovpn on tin- 
hack, and thuM ttiu extonxor wvundl intcniodii may never a|i]Htiir at all. ThiN 
may norm a rptincmont. but the fret-dom with whieh 'the thumh and tinkers can lie 
extended, even within a day or two of the o|>i'ration. when tblH |ioint M attondfcl to, 
who ws that it is ini|H>rtant. The articular facet un the ulnar aiw* of the bone 18 (hen 
eli|i|M'<l away with forceps u|)|)lied lonjjitudinally. 

If the hones prove to Ik," deeply carious, the forceps or }{on>!e Muist he used with 
the greatest freedom. Tlie metacarpal l)ones are next (lealt with on the same 

Iirineinlc. If th«>y seoni wound, the articular Hurfare.s only are ilipped olT, the 
literal facets being rcinovetl by longitudinal application of the lioni'-forcc|w. 

The traiieziuin iH next neised with foreepti and dinwcted out without cutting the 
tendon of the flexor can)i radialin, which in fimdy Iraund down in the groove on the 
iml"iar HM|K'ct ; the knife iK'ing also kept close to the bone so aH to avoid the radial. 
The thumb U-ing then |inshed up liy un assistant, the articular end of iti< metacarpal 
Ixine is n>move<i. Though tbiit articulates by a separate joint, it may be affected, 
and the tiymmctry of the hand is promoted by reducing it to the same level as the 
other metaear|)nls. 

Ijistly. the articular surface of the pisiform is clip|M'd off, the rest heinfj left if 
sound, as it gives insertion to the tlcxor carpi ulnaris and attachment to the anterior 
annular ligament. J{ut if there is any suspicion as to its soundness, it should he 
dissected out altogether ; and tlic same rule a|)i)lies to the jirocess of the uneifurni. 

The only tendons divided are the extensors of the carpus, for the 

flexor carpi ratlialis is iii.seitod into the second iiietacarj)al htslow its and so escapes. Only one or two small vessels recjtiire ligature. 
Free drainage must be given. The hand and forearm are put up on a 
special splint with a cork support for the hand, which helps to secure 
the principal object in the after-treatment - viz. freijuent movements 
of the lingers — while the wrist is kept fixed during cuusoUdation. Passive 
movement of the fingers, whether the inflammation has subsided or 
not, is begun on the second day and continued daily. Each joint 
should be flexed and extended to the full extent jio.ssible in health, the 
metacarpal bone being hold (piite steady to avoiti disturbing the wrist. 
By tliis means the sujipleness gained by breaking down the adhesions 
at the time of tlie operation {m'C p. 1 i.'J) is maintained. 

Pronation and supination, flexion and extension, abduction and 
adduction, must be gradually encouraged as the new wrist acquires 
firmness. When the hand has ac(juiied sufbcieiit strength, freer plav 
for the fingers should be allowed by cuttiii" olV all the splint beyond 
the knuckles. Kven after the hand is healed, a leather support should 
be worn for some time, accurately moulded to the front of the limb, 
reaching from the middle of the forearm to the knuckles, and sufficiently 
turned up at the ulnar side. This is retained in situ by lacing over 
the back of the forearm. 

(2) Oilier s Operation' (Fig, ."){•). Xo surgeon speaks with greater 
weight on excision of the wrist than the late celebrated surgeon of Lyons : 
none have had .so much operative experience, and i.o one worked so 
hard in order to bring the operation into better favour, and to insist 
on the necessity of attention to minuteness of detail both during the 

' .M. Oilier claimr-d that hy his Tni thml. which must he. as far as possihic. subporinstcal, 
iKit (ine attachment of the ten, Ions need he lest. Hy other" methods the attachments 
of the extensors of the carpus. thf)se of the Hcxor carpi ulnarin and radiaiis, and perhaps 
that of the supinator longus, are, he maintains, usually sacriticed. 



pcrfornianco of tho o|M'riiti<)n iiiul in the iift<'r-tr<«iitin<Mit. Fiimlly. 
M. (Hlit'i- not only luxl iinri vallrd cxpfiiciici' in the fxci.sion of this joint.' 
lint he has icpcati-dly. t-ithiT hinisi-lf oi 'liy hin impils. [(hiicd liis results 
licforc the profession. - 

M. Oilier, havinjj tried svverul iliireroiit iiu-isiuiiii, rmiiuiiieiiils the 
foilowiii};. At tirst sight 
the number (three) ap- 
pears complicated, but 
it will be remembered 
that the third that 
iivr the radial styloid 
pntcess is merely for 
drainage. With a view- 
to simplify as much as 
possible what must in 
iiny case be a very com- 
plicated operation, a 
siiii;le dorso-radial inci- 
sion, the chief or meta- 
carpo-ratlio-dorsal one of 
( )llier, may be employed. - 
From respect anti in 
justice to that excellent 
surfjeon, his operation is 
L'iven ill detail. Much of 
it refers to advanced cases 
of disease. It should be 
the object of all con- 
cerned to antedate this u 
stage. The parts having b' 
been made evascular by 7, 
an Ksmarch's bandage, 
and all adhesions broken °" 
down, the hand is sup- 
ported, extended, and 
|)ronated by a sand 

First stw/p. Incision 
of Skin and I.itjaments. 
The surgeon, comfort- 
alily seated, makes the 
lirst and chief incision, 

metacarpo- radio- dorsal, starting from a point in the centre of a 
line drawn between the two styloid processes, and running down- 
wards, at first vertically and then somewhat obli(|uely outwards 

' Traill dia Hfun-tionn, ISSS, t. ii, p. 448; Hi^irlioiis <li ^ ijriiiitli!< Arl.ntliiliun", ISi 5. 

^ M. OlliiT hinisolf, loc. Hii/irn cil. Cuiujrcs Franc, de, Cliir.. ISiM, p. 872; uiid 
Rrieelionadenyrandt i Ariirulaliuni, 1895. M. Uangolphe, " Xumcur blanche dii I'ciijjtu't." 
Tr. dr Chir., IHiMl, t. iii, p. ,jt»."> ; Dr. Mondan, "La Tubcrciilose du Poignt't," H^i: dr 
I'liir.. ISlMi. p. 180. 

'■ 'VhU im thdd iif cxcisir.n hy a singU' ( iiK was iir,~t i-mpldjcil liy 
l!nr( kil :ui(i l.niii;inlM(k. Kixiii r ( j( Himl: nj l)i„raliir Siiryi ri/, lllll) di'scVilics a 
iiinili' of ( xc i^iiiri tlinmirli ii : iiii.'lc (luisd-uliiur incision, i'xU'IkUiii; from the inidilk' of tin- 
lifth iiR'tatariml upwards over tliu iiiid<llu of thu wrist joint, and from theiico along the 
middle of the back of the foniann. 

Kic. .">!•. 'I'lie tendons eoiucrned in exeision of the wrist. 
A a', b h', ( ( '. 't he three iiic i-ions ii-iially ein|i|oyed hy 
M. Oilier. I), the ineision of Uoi'ekel, soraotime8 de.serilHMl 
as iAngenbvuk's, the two being practically identical. 
R, RadiuH. r, I'lna. 1 and 2, Radial e.ttcnsors of the 
carpus. 3. Extensor ossisnietacarpi iHillieis. 4, ExtenHor 
primiinternodii. '>, Exten.sor aeeundi interiiudii. f>, Kx- 
tn.sur eomniuni.s. 7, Extvnsor indicix. 8, Extensor 
mimmi digitl 9, Extensor carpi ulnaris (Oilier.) 


along the initer riiic of the pxtpimor indicis. and ending befciw 

over till' sc(t>ii(l mctaniriml lioin- at the junction of its upper two 
anil lower thinls. A sulMiitaii.oiis brjnrli of th" rmlial nerve haying 
Im'ii. if j)o8»ibli'. nvoiili'il. tin- incision is carrii-il tlowii to tlit> pi'iios 
teuni anil dorsal liKninents, great care heing taken not to injure 
the extensiu- indicia and the extensor carpi radialis hrevior. The 
extensor indicia is first recognised, but its sheath should not he opened 
as the incision is deepened. It should be drawn aside with a blunt hook 
so as to expose the tendon of the extensor carpi radialis brcvior, the 
insertion of which it conceals. The perio.steuni over the base of the 
third nietacariml is next itici.sed so as to admit of the detachment iif 
the last mentioned extensor, togeiher with its periosteal sheath, which 
constitute the radial lip of the deeper part of the wound. The incision 
is then prolonged upwards along the foreann according' to the amount 
of bone to be removed, and over the anntdar ligament outside the parti- 
tion common to the extensor indicis and communis. A little higher np 
the incision passes between the extensor indicis and the extensor secundi 
internoilii. tendons being drawn resjiectively inwards and out- 
wurils. In the highest part of the incision the jjeriosteum over the lower 
end of the radius should be divided. 'I'his incision should be four inches 
or more in length, so as to avoid neeilless bruising of the soft parts, 
and to give adequate access to the disease. The ulnar incision is next 
made, starting about one inch above the styloid process of the ulna, 
and ending below over the base of the fifth metacarpal bone, the incision 
being kept rather towards the palmar surface so as to leave the tendon 
of the extensor carpi ulnaris above in the dorsal lip of the wound. The 
incision should be made carefully so as not to injure a filament of the 
ulnar nerve which crosses it, and thus not comi)romise the sensibility 
of the little finger. The incision is deepencil down to the cuneiform 
and unciform. A third incision, for drainage only, is made about an 
inch long over the styloid process of the radius. It should be made 
now. betore the landmarks have disappeared. 

i<emnd sUuje. Removal of the Bom s. This is facilitated by division 
the posterior annular ligament, which allows of easy separation of 
the tendons. The radio-carpal joint having been opened, the periosteal 
and ligamentous connections of the carpus are gradually divided, and, 
the carpus having been made to project more and more above, the 
flexor tendons are safely detached and held aside in front. It does not 
matter which of the carpal bones is taken first, whether those that lie 
beneath the radio-dorsal or the ulnar incisions ; as soon as one is removed 
the extraction of the others becomes easier. The great aim of the 
surgeon is to remove each diseased bone completely. Being very friable 
they are easily crushed, and any diseased part that is left adherent is 
liable to cause a focus of infection and tedious suppuration. 

Each bone should be turned out of its periosteal and ligamentous 
adhe-sions with a periosteal elevator or gently seized with small forceps 
and any adhesions carefully divided. The pisiform usually, and often 
the trapezium, may be left, and the unciform if sound. Otherwise, 
if difficulty be met with in sheUing out this bone, the process may be 
cut through, the bone itself turned out, and the process subscqucnlly 
taken away. The lower ends of the radius and ulna are now examined, 
each from the incision over them, and dealt with according to the amount 
of disease present. Thus in some cases erasion with a sharp spoon or 



ffoxtffi may be snflicieiit. In othen the ewib may be removed, » raMll 

H iu i»''\ng HO ii(W'(l as to form a new articular oml. Tlio styloid procosHOH 

iil<l always he li-ft. if |)o»,sil)l»! ; anil fvi'ii wln-n all tlio articular cavity 
III' tlic railius must pi. sonic of the cxpandcil end of the honi- should 
l»' left so as to furnish u solid support for the hand. The periosteum 
.ill roipid each hone, ami lateral li|{aments, should bo carefully retaiiu-d 
when healthy. In yuung Hubjectii the operator must Ik^ careful not Ut 
Irave a raMeating Be<|uestrum in the epiphvHial line above a oet'tion of 
hone which is ap{mrently healthy. The same remarks apply to the 
treatment of the fiuir inner nietacar|Nils. which alone are usually diseas««<l. 
The of any of these \vhi<'h reipiire removal must he most carefully 
shelled out of their fibrous coverings, or the teii(h)n» and deejH'r pulniur 
arch may be damaged. If more than gouging is required, the section 
is lM>tter niudc with a fine saw than with cutting forceps. 

(^teHion of Preservinij the Ptrittrteum. This step has been objectetl 
to on account of its increasing the risk of leaving tuberculous inis< hief 
behind. M. Oilier strongly udvi,. utes the 8ubjH>riosteal metho<l. Though 
riddled with listuhe and infiltrated with tuberculous graiuilation-ti.ssue, 
the periosteum should be jire.served. as inucli tt.s is possible, after thorough 
curetting. This will aid in making the coinu'ction betweei» the meta- 
carpus and the forearm strong and not tiuil-like, while it will also help in 
the preservation of the carpal tendons. Professor Oilier meets the above 
objection by a thorough use of the cur(>tte until only the actual fibrous 
tis.sue of the capsule, ligaments, and periosteum is left. Theoporationisa 
tedious and dillicult one, recjuiringthe care, througlutut to avoid 
injury to important .structures, and to get away all the diseased tissue. 

th ird sliKjc. Toilt ttf. Co uU riMtim, and Drainage. M. Oilier attaches 
great imp<irtttnce to these |K>ints. 

Toilette. The tendons usually lie buried in tuberculous granulation- 
tissue extending upwards and downwards to a varying degree. Every 
infected tendon-sheath be slit up, and the tuberculous material 
I'oildwed into every nook with .sci.ssors and curette. Kach tendon must 
be individually drawn up with a blunt hook and inspected. To render 
the deeper ones accessible they should be pushed up from the palm 
and, if it be needful to get directly at the flexor tendons, one or two 
incisions should be carefully made in the palmar surface. 

Caut sation. M. Oilier advises the use of the actual cautery to 
the most affected spots, with the view (1) f>f helping to eradicate the 
(li.sease : (2) to prevent luemorrhage ; and (3) to obviate the risk of 
tuberculous infection from the wound. 

Ihdinujc. Dn,' • of gauze should be freely employed between the 
ilitierent incisions, uot oijy to prevent collections of fluid, but to keep 
the incisions open in tase futther curetting should becalled for. The 
dressings should be voluminous and firmly applied, so as to distribute the 
free oozing through a large amount of material. The Esmarch's bandage, 
wliichshould have been put on high up in the forearm so as to admit of the 
application of the above-nu'iitioned dressings, is then removed, and the 
limb put on a Lister's splint, while thewrist is kept extended. Another 
very efiicieut splint which can be more readily sterilised is one recom- 
mended by Mr. R. Jones, of Liverpool. It consists of a simple anterior bar 
of sheet iron with two H -shaped extremities. These are bent round and 
grasp the limb just below the ■ 'bow-joint above and just above the 
inetacarpo-pbalangeal joints below. The part on which the hand rests 



should be bent at an anffle nf about forty dpgroos, ho that tho hand 
be kept extended. " If any one wishes to jrrip |M)\vi'rfully the wrist 
U tirot instinctively extenili-d. One cannot efTcctively ^rip with the 
hand in the He.viHt' poMtion. " The first <lreH**in){ shouhl l>e h-ft on. if 
powiblit. fur eight or ten days. If needful the ineisioim niufit be kept 
open with drains (or three or four weeks, that any suspieiouit itrannlation- 
tissne may be repeatedly attaeked witli the Hharp H|HH)n. 

After-trenttHfnt. Thw iinist he h« >;un a (hiy or two after tlie opration. 
and lie persevered witli for six or nine months, the pnticnt Irndio}; an 
untiring aid tliroujihout tlie whoh' of this time. A "lay or two after the 
o|M>ration the ♦inner-jointH shouM la- moved daily, i.ire licinf; taken not 
to disturb the wounds, and especial attention should be given to the nietu- 
eiirpt)-phalan}.'*>al joints, which are liable to escape attention. Moreover, 
the thundi and index filifrer nmst be kept well apart. Alxmt eijfht or 
ten days after the operation, or as soon as the jmrts are miffieiently 
solid, eareful movement of the wrist may he l>e^;un. There u a JHT- 
.sistent tendency for the tendons to remain adherent in their sheaths, 
only to be overcome by jjersevering. assiducais moveni'Mi*- 'vifh 'he 
help of nitrous oxide gas from time to time, (ialvaiiism. hiradism. 
friction, massage, are all of service when the wound is healed. If the 
surgeon wishes for a good result in the {-ase of hospital |)atient8. he will 
not allow them to leave too early. As M. Oilier points out. and as his 
eases show, in addition to excellent movements of the fin<;ers. cxfeiision 
anil flexion, abtluetion and adduction of the hand on the carpus sliould 
be very largely re<overed by long-contiiuied perseverance. Extension 
of the fingers auvl wrist is more slowly regained than flexion, owing to 
atrophy of the dovsal muscles and matting of their tendons.* 

Kven if the otli.r fingers are stiff, mobility and power of approximation 
of the thumb and index will be much more useful than any artificial limb. 

The following is one of the cases of excinim of the wrist by Ollier's 
method j)reviously referred to : 

Mrs. l).,a't.:n, wii.-<!«'nt to Mr. Jiu'olisoii in .liiniiiirv ISlHi. liy Dr. Wcxxl. of Dovor, 
with tutMTculouM cli.sfaHC of the riulit wrist. Tlirri' was tlmriioti riHtir Mw<'llin){ on 
\mth iisiK'ftM of the wrinf.tlif liiigiTs were stiff iiml cxti iulid. iiml llic Imnd useless, 
hut tlii'ri' were no siiuiscs. Tlicujic and tlic pcixmal hislmyof the jiatii iit were also 
favonnililc. E.Xfision was iiorformcd hy an cxtcn-iuM of Ollici s iiiciliaTi dorsal 
incision. Tin- pisifoi'n and tin- traiH'ziiini were left. Tliin slices of the articular 
ends of the radius and uln.i were ri niovcd. hut it was only needful to tn at tin l a-es 
of the four inner metacarpals \>y vigorous curetting. Two lateral incisions were 
made for drainagi'. The woumls healed (juiekly. After-tivatMicnt could not he 
satisfactorily carried out owing to the irregular attendance of the |uitifnt. In 
November fsSM. Dr. Wood wrote : " There in some undue ]iroiiiinence and mobility 
of the end of the ulna. PronRtimi and supination are ]HTfert and raintetw. Th<> 
hand can '"e flexed and extended to about half the normal amount. Tlie niovenu-nts 
of the thumb are perfect. The movements of the flngers at the inteqihalnngeal 
joints are (lerfect. but there is Honio stilfness at the metacarpo-phalaiigeal joints 
whii h jirevents her from ' making a list." Generally, she has a thoroughly useful, 
though at present not a strong hand." 

This rigidity at the nietacarpo-phidangcai joints was due, in |iart. to too much 

' The ahove remarks refer only to cbbcs of advanced tulieieiiliiijs disease. W hen 
exci.sion i.- (MTformed early Iwfore the stage of unuses. Ac a« should always he the casi'. it 
will often he ]Missihle to erailicat<' the tuln-rculous disease at the time of the opeiatinn ; 
the dressings will he few. and the after-use of the ciiri tte only <H casi(iiially m eded. 

^ It iius Ijeeii su)£^ested that some «»f the loss uf poHer lu the tinsels and wiist depends 
on the tendont* remaining too long after the removal of the diseased hones, and that 
shortening of the tmdons should be practised. M. Oilier only recommends shortening 
of tendons when the fingers tend to be obstinately flexed ; he advises in this case 
■hortening of the dorsal tendons by his method given at p. 104. 



ittli iitiiiii iH iriK (tivrii to tlir iiiti'r|ihiilaiiK<''il jiiiiilN. iiiiil In ths fwlimt U'liiu Innt xixhl 
III tiHi HiHiii. Il II lixiilily lit llir fiiniiri Joint" H'hii'ti |in'VciitRng<NMl ri'Niilt Ih iiikiiu 

r\i < III Ml oltr. rllliltlilllil, IIH it llmM. ii i rrtilltlllt'^Dl' of o|»'ll rlaw, InHtcilll o( il I'Iiiki'iI li»| , 

QsMttoa of AmpnUition in Tab«renloiu DImhc of theCarpui. \>* has 

\ieen stated above, tuberculins iliiH>UMi> of the curpiw inorf run-ly 
orcurs alime and iaolatetl than any other tuberculous joint allcctitm. 
Tlitw the pxwtence and AofiTvc of other tiihemilouR leflionn. the extent 

111 tilt' disease in tlie wrist, the a>»e and vitality of the patient, the personal 
,iiid family history, the |ire.Hence of albuininiiria and lardaceous di.Hea.He, 
iire some of the chief points whieh will help in deciding; the above ipies- 
tion. M (tllier has recorded seven cases in which, owinx to the exist- 
I'tire of a Clinch, ha-iiioptysis, and su8]M-cted or actual di.scase of tlie 
apices, he advised ainputiktion, but performed resection owing to his 
advice iM'injf rejected. The results were not enconrafiinft. While 
excision of the wrist deserves a trial on a larger .scale than it has hitherto 
received, it should only be attemiited in patients whose vitality is 
siiHicient, and who are not haixlicapped by .serious disease elsewhere. 
Where amputation is decided on it iiumt be through the forearm. 

Excision of tba Wrist for Injury. This will be still more rarely reipiired. 
I'artial excision may be indicated in rare cases of dislocation of the 
wrist which are otherwise irreducible, in mtine cases of unreduced separa- 
tii>n of the lower radial e])iphysis, and pos.sibly in some of compound 
fracture.- of the lower extremities of the radius. 

Excision of Wrist for Ounshot Injury. 'I he first step will be to render 
the wound a.sejitic if po.ssible. to remove any shattered fragments, or 
to perform a partial excision (according to the amount of danuiKe). and 
provide sulUcient drainage. If the wound suppurate it should Iw 
irrigated ; and, if the infection prove intractaMe. the wrist excised. 
M. oilier' gives an instructive case of primary partial excision (first row 
(if carpal bones and the ends of the radius and ulna) for a gunshot injury 
ill a lad. u't. |."?, The shot had " balled," and the extensor tendons were 
severely daniuged. The case was kept under observation for seen years, 
and the last report ends : " As far as the daily use of my hand goes, I 
might say that I have never had a wound." 

These injuries are most likely to occur in military' wrgery. In 
former days, when the projectile was large and the velocity slow, injuries 
of joints were extensive and serious, and likely to reiiuire amputation. 
K.vcision on the whole gave poor results. Thus (luilt (ijuoted by M. 
Olli'' I in examining into the results obtained by the (ierman surgeons 
in the Franco-Ucrman War, only found one good result, eight moderately 
giMKl. six bad. and one very bad. 

The conditions of modem warfare have so altered, and the arrange- 
ini'iits for treating the wounded have .sf) improved that the experiences 
of surgeons in the South .Vfrican War as to the treatment and prognosis 
of these injuries are of very great interest, 

.Mr, Makins- does not mention any case of injury to the wrist-joint, 
but at p. 2'M the words occur : " I never saw any troublesome results 
from perforation of the carpus." 

Colonel Hickson. R.A.M.C.,' writes as follows : 

> Tmite del Siseeiioim, t. ii, p. 404. 

- f^Mf^p'ffll EjeptrknftiinSunlh.lJrirtt.lHdO 1900. 

' H' ixirli hi SnrgienI Cum i in ih Sniilh Afrirun War, 1899-1902. Edited by 
Siiigniii-IJoncral W. F. Stevfnson. t'.B. In tin- present war the prognoxis in these and 
other similar injuriesUmuch less favourable, the s^iecial conditions greatly inctpaiiing the 
danger of infecuoo and sopparstion. 


"<)i:ly tell cx/iniplcs of w<nin<l;< <if the wrist-joint liavi' liccii lollci lid. Wlirn 
I)r(Hlii(<'(l l(y the liiiidciiscd Ipullct. injuries of this joint a|i| to lie ahnost in- 
variably |>nrc I II rf orations. Iicalinn quickly under a seal) ulieii aseptic, and causind 
little or no permanent limitation of movement. In two of the recorded cases frag- 
mi nts of tlu' enrpal l)ones were removed, the injui ies liaving been caused hy revolvrr 
or Slartini-Henrj- bulletn. No case necessitating amjnitation hag been note<l, and 
there is only one recorded instance of excision of the wrist-joint. The case in 
question, one of my own, in which the bullet, coiwiderctl to he a ricochet, com- 
pletely shattered the left wrist-joint, disorganising the carp\is, and tissuring the 
lower end of the radius. The wound was very septic. At first the injury seeuifd 
to call for lunputntion, but eom])lete excision was carried out as an alternative," 

"Convalescence was prolonged, the arm bath being constantly used for weeks, but 
he eventually recovered. At the time of invaliding, the movements of the fingers 
were fair, but those of the wrist very limited."' 

CuMt of FftUnn after Excision of the Wrist. These are mainly : 
( I ) Persistent sinuses and discharge set up by romaininf; foci of infective 

tiilicrciiIoiiR firaiHilatioiis. caries, or iiocro.sis. 8ir W. Fcrf/tissoii' sliowcd 
a .sj)c(iin»'ii ill wliicli all the bones were .suppf)sed to have ix'cn icniovcd 
by a .silicic iiuisioii on the ulnar side. The pi.siforin. trapeziiini. and 
part of the unciform had been left. The movement of the fm>;ers was 
good, but sinuses remained on both sides connnunicatnif; with a bare 
piece of radius. Death took place from phthisis. (2) Matting and 
sloughing of tendons and consequent stiffness of fingers. (3) Phthisis 
or other tuberculous visceral disease. 


In some cases of Colles's fracture, where the fracture has not been 
reduced and the hand is therefore greatly disabled, if the patient's age 
and vitality be satisfactory operative steps will lead to great improve- 
ment. A long incision is made over the radius on the dorsum, ami the 
line of union exposed by retraction of tendons, division, and sej)aiati<)n 
of the periosteum. The union is then di.ssected throiigh from behiiul 
downwards and forwards, the fragments completely detached and 
placed in correct position. As their surfaces are broad they will remain 
in position without the aid of wire, &c. As the fracture is now com- 
pound and the patient probably no longer young, splints must be kept on 
ff)r about four weeks, and some support given afterwards. Pas.sive move- 
ment of the fingers should be begun at once, and the wrist moved, carefully, 
in about ten days. In separation of the lower epiphysis, which has been 
overlooked, deformity and arrest of the growth of the radius are very 
likely to follow. This condition must be treated on .similar Hnes. with 
a view of rectification of the displaced parts. If this step is not taken 
or fails, removal of part of the lower end of the ulna may be required 
later on. in order to keep the articidar surfaces at their proper levels, 
and to prevent radial displacement of the hand. 


(Figs. 60, 61, 62) 

The viiliie of this operation has been a good deal disputed. It has 
been thought by some that it possesses no particular advantage ; the 
length of the stump is of no great consequence ; the flaps with the 
numerous tendons in them may not heal readily. Others have gone 
further, and said that the long stump is found by instrument-makers 
* Polk. 8oe. Trans., voL Tiii, p. 391. 


difficult to fit w-ith an artificial hand. That this is cortainly not always 
the case is shown by Mr. H. Bigg' from two cases, one a coininandcr 
R.N.. the other an artisan in the Woolwich Arsenal, both of wliuni, 
after heinj; fitted with artificial hands, were able to engage actively 
in their employments. 

As the above objections are scarcely sufficient, and as this amputa- 
tion preserves, if the parts heal quickly, good pronation and supination, 
it should be practised whenever opportunities arise. These, however, 
as is shown below, will not be numerous. 

Indications. (I) Extensive injuries (u'unshot and otherwise) of a 
hand not admitting of the preservation of any fingers, and in wliich 
the damage of .soft parts does not necessitate amputating through the 
forearm. On this subject refer.'iice .should b' made to the section 
on " Conservative Surgery of the Hand. " p. 71. 

(2) Some cases of tuberculous di.sease of the carpus, where sullicient 
skin and soft parts are healthy, but which are too far adviuu cd, or are 
rendered by age, condition of health, Ac. unsuitable for e.\( ision. 

(3) Cases of failed excision. But in carpal disease the soft parts 
are often so much damaged by sinuses and other results of the disease 
that the surgeon is driven to iimputate higher up ; and where this may 
not be the case, the articular surfaces of the radius and ulna, owing to 
disease, have to be removed, the operation thus ceasing to be correctly 
amputation through the wrist-joint.* 

(4, 5, and 6) More rarely still, for the results of palmar suppuration, 
gangrene, or burns. 

(7) Some cases of malignant disease, e.ij. ejnthelioma. All the above 
are rare. 

Operations. As in other amputations where the amount of .skin 
available varies considerably, several methods will be given. The first 
of these is the beat. 

Diflennt m^ods. (1) Long palmar flap (Figs. W and «il ). (2) ?:i|uul 
antero posterior flaps. (3) Method of Dubreuil (Fig. (»2). (4) Circular 

(I) Ampulation hij a Lomj Palmar flnp (Figs. IV) and lil). This has 
the advantage of preserving skin thick, well usetl to pressure. an<l 

Fl<;. (K>. Amputation thrtiiisrh wrist l>y loiiK pHlnmr llap. Ainpiitution 
through forparm by long antorijir and short iHi.sUTior Hajw. 

abuiulantly supplied with blood ; the nerves are also cut scjuarc, and 

disarticulation is easy. 

' Arlifirinl Limln and A m piiltiliiiiix. p. 8.1. 

- Disarticulation has tlie.-ic ndvantapes over i ntiii- n iiKival nf tlii' slylniil pioi (•».•<(>.•< 
(i iV/r infra): (1) There i« no risk of necrosis. (2) Hotationof tlic forcanii is not interfered 
with, the inferior radio uhiar joint being left. (;$) The supinator limgiis i..* left to i«iwerfidK- 
flu the fuwtrm. (4) The ituaap ia kogw mmI mora uiefiil 


The brachifil artorv hfitifr controlled by a touniiciiu't. the liinh i.s 
broufiht to a rif;lit aiif;le to the patient's side, and the hand, supinated,' 
is siippDrted bv an assistant, or rests on a sterilised towel on a sn>all 
table. The wrist is now e.xtt'ndfd. the .styloid processes dclincd. and 
the thumb abducted .so as to make the pahnar ti.ssiics tense. .\n incision 
18 next made (r)n the left side) from the tij) of the .styloid process of the 
radius^ straight down well on to the thenar eminence, and then curving 
across (about on a line with the level of the superficial palmar arcli), 
and markiii}! out a well-rounded flap by passing over the hypothenar 
eminence to the tip of the styloid process of the ulna. This flap is 
next dissected up. without .scorinj:. to ensure its vitality, cleanly <)ff 
the flexor tendons, as far as the level of the : it should contain 
on its under surface some of the fibres of the thenar and hypothenar 

If this precaution be taken, the flap, if sound, w ill contain the super- 
ficial volte and ulnar arteries, and thus run no risk of sloughing. In 
cases where the (! ij) is damaged it will be wisest 
in making the tlap to cut all the .structures 
ilown to the bones. Cheyne an<l Burgliard 
advise that it facilitates the operation 'to 
detach the pisiform bone and raise it with the 
palmar flap; it can easily be dissected our 
afterwards. The hand beingnow pronated and 
flexed at the wrist-joint, an incision, slightly 
conve.v. is made across the wrist from one 
styloid process to the other. The palmar Hap 
beingnow retracted, the hai il is strongly flexeil 
and the joint opened on the other side first ; the 
soft parts in front and behind are next severed 
with a circular sweep (the assistant ])ulling 
slightly on the hand), the remaining ligaments 
Fi„. (il. divided, andthe hand removed. .\t this stage the 

extensor tendons nmst be cut b(jldlya!ul cleanly, 
otherwise they will be ragged. If the articular cartilages of the radius are 
diseased, they must be dealt with either by gouging or, if necessary, by a 
clean section above the articular cartilage, a step which will interfere 
with free pronation and supination later on. The apices of the styloid 
processes should in any case be removed, but the base of that of the 
radius should always be left, if possible, to secure the action of the 
supinator longus. In amputating at the wrist-joint care should be 
taken, by keeping the point of the knife towards the carpus, not to 
open the radio-ulnar joint, so that there be no interference with 
pronation and supination. The radial, ulnar, the two interosseous, 
and the superficialis volte arteries will probably need securing. Any 

' If the (ipcriitiiiii is. tliiiH. ('(immcm cmI from tlu' ficnit. tlic liiinil tici iI mily lir tiiiiii il 
ovrr (im c. If tlir iliirsiilii i» attackcil liist, the hand liiiisl lie tiiiiii <l r. liist to iii.ikc 
till' |Kilin:ir flap, and Kercindly to disnrticiilato (Faralx<iif). 

^ Til' lip of this is npurly on a IpvoI with tho intcTrni')ml juint. hcina half an inch 
below and .scincwlmt in front of the styloid prmrss of the nlna. On a level with the 
latter will lie found the line of the wrist joint. 'I'lip tw^o furrows in front of the wrists 
are l)olh helow the level of this joint. The lower one corresponds tii the iippi r edye 
of the anterior annular ligament and the inlerearpal joint. If the suft part- are 
much ewollen, eoiii|iariHun with and nii'a»nrrnii'nt» taken from the c)p(K).site wrist, will lie 


simisos j)rosent aro now scraped with sharp spoons, and the tendons 
tiiniitifd. Kioiri flu- facility with whifli those last slip up into their 
sheaths, precautions slioultl he carefully taken to avoid iofection. 

Amtthrr Method.— Thin coiwidls in iiiiirkinR oat the palmar Hap (bat not 
(lisMfcting it up), opening the joint liy a dorsal iiii ision as ({ivi ii above, and then 
rnttinf! the |>nlmitr iliip l>y transtixion, tln' knife l>ein« passed iiehinil the lM>ni>s. A« 
in this met hod it is dittieiilt to avoid hiteliint; the knife on thi' pisiform anil niiiiforni 
liones, and to obviate a jaum'd ed)?e to thi' palmar llap. and as the llexor tendons. 
iM'ing rela.xed. are pnlleil out by the knife instead of Immiiu ent eleanly. it is not 

(•_') AiHiiiildlliin III/ Eijiiiil Atili rnl'dil, rinr F/iiji^. The snr^teon may \>r obliged, 
where till' soft paits' are s( anty. to make nse of this method, 'I'he objeel ions to it 

are ;!ial if the tissues an- thin there is si risk that the eieatrix may !»■ adherent to 

the bones, and tlial these will be bnt |H)orly eovered. 

(:t) Aiiiiiiittiliimiilllii W'ri"! I)i/lli< Mflhijti of DiihreiiU {Vin- *V2). Ina very few rar»' 
eases. f.(f. where the Koft jiiirtd on the Imek and front of the w l ist are niueh damaged. 
|Hiforate<l by Kinuses, &e.. thlH ingenioas 
method may "lie made us*- of. Hat the objj-e- 

the thumb is 
> irts for a 
' iH'inf; 
I point 
little below 

tion to it is obvious. Where 
saBieiently healthy to afford 
tlap, it shonlil be H)ive<l. '1 
|irona»eil. the sinyeoii eoinii ■ 
at the jnnetion of the outer i 
third of the baek of the forearm 

Flo. 62. Duhreuil's amputation. 

the level of the wrist-joint, a lonvex ini ision. 
wliii h reaehi s at its summit the middle of the 
dorsal sinfaee of the thninb. and terminates in 
front, jiisi below the palmar as|M'et of the wrist, 
at the jmietion of the outer with the miihlle 
lliirds of the forearm. The Hap, consisting of 
skin and fasciie. having' been raised, the two 
ends of its base are joined by an incision at a 
rieht ani:le to the long axis of the forearm. 
Kinallv. ilisartieiHation is ix-rforim-d, beginning 
at the'iadial side. If needful, the flap may be 
taken from the hy|iothenar eminence, by re- 
vcrsinj; the ineisions. 

(4) Circiilnr Am iiutnliim til the Wrist. This method is only suitable to 
patients with thin, lax skin, anil even to them it is often dirtieiilt to raise tile skill 
ipiiekly and neatly, for it is lu re adherent to some of the adjacent parts, as at the 
liase of the hypotlienar einineiiee. .Moreover, eiittin^' through suih a thin, lax 
skin may be fiiilowed by slougliin)i. espeeially if its vitality is impaired by sinuses. &c. 

The hand beiiiL' sii|iporleil by all assist.iiit. the surneon draws up the skill of the 
foiearm. and makes his lirst eiiVnlar ini ision thniagh the skin on a level with the 
earpo-melaearpal joints of the little linger and thamb. encroaehing thus ii|Kin the 
thenar and hypotlienar eminences, two inches Mow the styloid procj-ss. The 
skin bciiif.' retraeted by freeing the soft parts with ifght touches of the knife, another 
cirt ular sweep is made just above the level of the pisiform bone, so as to sever cleanly 
the numerous tendons, together with the vi-ssels and nerves. ' ' ' ' 

o|M>n<Ki and the styloid process removed 

The joint is then 




(Iiiiilf. A line drawn from a point just internal to the ai)ex of the 
styh)id pnK-ess to the back of the interosseouB space. 

' The so-called " tahaticic nnatmniiiue.'" a triantiular space biiiinileil externally liy 
the exten.sor ossis metacarpi ami extensor priiiii interiiodii. internally by the extensor 
sccundi inlcrmitlii ; its ajiex is foraied by the meeting of thc«e tendon-", and its luusc by 
the lower etige of the posterior annular ligament or bow of the radius. 




Skin, fuwia' ; branc hes of supt* rtU-ial vein, and <tf radial and musculo- 
cutaneous nerves ; fibn>-fatty tissue beneath deep fascia. 
'I'liree extenscir tendons of the thumb. 

Out. tide Deep 
\' . coint's Styloid process ; scaphoid, 

trapc/iuni : cxtcriinl lateral 

lij.Miiit'iit of tlie wrist 

I iidiailiiins. Few; usually wounds. (.</. liy the slipping of a chisel. 
l)v hreakiiij; crockery. &c. Jn such cases lioth ends' Wduld. of course, 
he .secured, and the surgeon would examine a.s to injury of any of the 
exteii.sor tendons. 

Operation. The limb should rest upon its ulnar margin, steadied 
by an assistant, who with one hand holds the fingers, and with the <»ther 

so moves the thumb as to make the teiHh)ns promiiK'nt. In the living 
subject these should be thrown into action, and their juKsition and that 
of the radial vein defined before the operation. The incision, one and 
u half to two inches lung, may be in the above line or parallel with the 
tendons. In either case it shcmld be over the lower part of the vessel, 
just before it dips between the heads of the first dorsal interosseous 
uito the palm. It should be made lightly, so as not to damage the 
railial vein or, deeper down, the tend(»ns. The radial vein having been 
tlrawn a.side with a blunt hook, and the deep fa.scia carefully opened, 
the tendons are drawn aside as needed and the artery sepaiated from 
its veins. The ligature may be passed from either side. The artery 
lies deeper than would be expected, usually covered by fatty ti.=sue. 
It will usually be tied between the bases of the first two metacarpals 
and to the radial side of the extensor sectindi internodii. If the parts 
jieed relaxing, the hand .«houId be hyperextended. All injury to the 
closely contiguous tendon-sheaths or joints must be avoided ; and, 
for the sanie reason, union of the wound without suppuiation is parti- 
cularly indicated here. 

In the following case a.septic surgery and the tying of diseased arteries 
with sterili.sed .silk, and not too tightly, answered well : 

.M. .\. S., a t. (;o, was sent to -Mr. .lacolwon, NovpiiiIh t 18!t!t, by Dr. Veriall. with 
ail aiuiiiysin <if tlic rifrlit aniial artery. I'aticiit. old for licr years, was oiierated 
on for lataiact at 4ti. .'^uijerllcial arteries tortuous and liaid. No evidoiue of 
luait ilisra.'^e. An aiieurysiii the size of a large walnut on tlie outer anil dorsal 
asj ict of the right ladius, jimt where the shaft and styloid proecss join, and extend- 
ing into the tabatii re nnatomique," had begun four years before. At first of the 
size of a nut, it gradually increased tUi a month before, when it became ra])i(lly 
larger. The radial was tied just above the Hwelling, and again where the artery dips 
lietwecn the heads of the abductor indicia. Steriiiwd silk woa used, and the veins, 
were inchuled in the fiiRt ligature. S})eeks of atheroma were seen in the radial 
aitery when exiio.sed above. The aneurysm was then incised and a good deal of 
pink laminated clot turned out. The wound ran an aseptic course ; the aneurysm 
shrank and disapiH>ared, the only trouble being some dermatitis caused by the 
iodoform gauze on a very aged skin. 

' It niaj- be diHicult to find the distal end of the aitvry. owing to its tendency to 

/ mide 
V. comes 



F:o. «3 




(Fijis. (>i. Cm. (id and <i7) 

In the upper two-thirds the artery is sub-muscular ; in the lower third 
it is sub-iascial. 

Line. From the centre of the bend of tho cllKtw (where the brachial 
artery divides, opposite the nrck of the radius) to a point just internal 
to the styloid process of the radius. 

(Jiiidc. The above line, and the interniusfular {{roove to the inner 
side of the supinator lougus and its tendon. The pulsation of the vessel 
can usually be distinctly felt in the lower half of its course. 


In Front 

8kin. fascia\ viz., superficial, deep, and 
another layer, varying in distinctness, 
which ties the racQal to the supinator 
longus and pronator ladii teres. 

Branches of the musculo-cutaneous nerve, 
especially below. 

Superficialis vola;* below. 

Transverse branches of vena; comites. 

Supinator longus overlapping for a varying 
amount and extent according to the 
development of the muscle. 

Outside Inside 

Supinator longus Pronator radii teres 

Radial nerve (middle third) Flexor carpi radialis 

Vein Vein 
Radial artery 
in forearm. 


Tendon of biceps. 
Supinator brevis. 
Pronator radii teres. 

Radial head of flexor sublimis digitonim. 
Flt'.vor longus poilicis. 
Pronator quadiatus. 



Indicatimu. (I) Wnunck, stalw, cuts with &c. (2) Trau- 

matic aneurysm. In these cases, after the applicution «if a tourni<{uet 
or an Ksmarch's bandufie, tlie surneon <i]>ena tlie swelling, turns out 
the ('li)t, iind li<;ature.s the artery above and l)elow. If he pr(>fers it he 
may snip out tiie sweliinj; and twisit or tie Ixttli ends of tlie artery. The 
first method is on the whole the most generally applicable. (3) Punctured 

Fl(i. f>4. A. lm-iKii)nforIi}!:itiiri (if 
tlio briichiiil at the t)oml i>f tlir 
<1I)()W. B, Incision for linatiiii' of 
the vcnsi'iit tin' rniildir of thi' fi)ri - 
aim. ('. Incision for linatiirf of the 
railial in the miiht third of the 
forearm, i), I mision for ligature of 
the uhiar in the Iowct third of the 
forearm, k. I neision for ligature of 
tlio radial in the lower third of tho 
forearm, v. I neision for exposure of 
the median nerve above the wrist. 

rill. (m. Determination of the centre 
of the iMMid of the elbow. The left 
index is placed upon tho epicondyle, 
I lie rii^lit upon the epitrochlea. wliilo 
the right thumb oceui)ie.s the; centro 
of tho fold of the elbow, to the inner 
aide of the bicops tendon which pro- 
jects beneath the soft parts. The 
line of tho radial artery has Iwen 
traced in it» intermuscular farrow. 

wounds of the pahnar arch. Ligature of both the radial and the ulnar 
is preferred by some, but reference should be made to the remarks at 
p. 89. 

A. Ligature la the loww third of the forearm (Figs. (i4 and (i(>). 
The forearm having been completely supinated and the wrist extended 
at first, the surgeon makes an incision, two inches long, midway between 
the tendons of the supinator longos «nd flexor carpi ladialis, or (if this 


be obscured by fat or by swelling) exactly in the line of the artery, going 
lightly* through the skin and subcutaneous tissue. A large hrnneh of 
the radial vein, which is usually met with in the subcutaneous tissue 
just under tho incision, is now drawn aside or divided between two 
lijtaturps. The deep fascia, here very thin, is carefully divided, and 
tiie wrist now fle.xed to re!a.\ the parts. The artery being separated 
from the vena' comites,- the needle may be passed in either direction. 
Damage to any of the tendon-sheaths sbiould be moat carefully avoided. 

Fli;. till. l.i^.itiiiT of the radial in its lower tliiril. Through the oprniiif; in 
the deei) fascia the artery is seen with its vcnic comiti'.s. Neither of the 
adjAccnt tendons haa liccn PxpoMdU 

B. Ligatun in the mSMIn thiid ni tb» foraatiii. Guide. Line of 

Relatioiiit. The nerve is now on the outer side of the artery, but 
not very close to it. 

The steps are very much as above, but the artery is lying deeper. 

The radial vein, if present, must again be avoided. The incision over 
the middle third of the artery should be two and a half inches long, 
and the parts well relaxed when the deep fascia is opened ; the inner 
aspect of the supinator longus is next defined, and this muscle drawn 

supinator and pronator must now be opened. The n^le should be 
passed from without inwards. 

Ligature in the upper third of the forearm (Figs. (>4 and (>7). Guide. 
The line of the artery and the inner border of the supinator longus. 

' So as to avoid the radial vein, which always, and the superficialis voI.t. which 
sometimes, lie sii])erficial here, the one over and the other just under the deep fasciii 
whieh is very thin. 

^ These, owing to tho free collateral venous currents, may be included in the ligature 
if it is found vHjr diffieolt to wprnte them frrat the Mtwy. 

which unites the artery to the 



Relations. The ncn-e is on ihe mitrr mlc but well retnoved from 
till' iirtcrv. The vessel itself lies somewlmt ohliijiiely as it j)asses from 
tlie iiiiilille i)f the ante-cubital space to the outer side of the forearm. 

It is iniportaut to rememltcr that the (levelopment of the supinator 
longus and the extent to which it overlaps the artery varies consider- 
ably. In a mu.scular arm it is very easy to get into difficulties by not 
hitting oi! the right inteminscular septum, uiul thus getting too neat 
the middle line of the for^rm, unless the line of the artery is remem- 

Fio. 07. Ligature of the radial juiit above the middle of the forearm. The 
Bupinator longug has been drawn aaide. The vessels are resting on the pronator 
radii teres. The radial nerve is to the outer side of the vessels and rather 
on a deeper plane. 

bered. An iiicisio.i. at least two and u half inches Um<i. is made over 
the upper tlutd of the artery in the above line. Any branches of the 
radial ve- • are drawn out of the way, or secured with fine ligatures. 
The -op fascia is .slit up to the full extent of the wound, alon^' a white 
lino which marks the interval between the supinator longu.s and the 
pronator radii teres. These muscles may be known by the direction 
of their respective fibres, the former goin<; straight down along the 
radius, and the latter obliquely downwards and outwards to the centre 
of this bone. The muscles having been relaxed by bending the elbow 
and and the cellular interval between them opened cleanly 
with a knife, they are ilrawn aside, and. if the vessel does not (juickly 
come into view, its pulsation may be felt for. The vena' comites having 
been separated, if possible, the needle may be passed from without 



(Figs. ti4, (iM. and «9) 

Line. The gurfacp-niarking for the lower two-thinL of the vessel 

will he a line drawn from the tip of tlif ii)tt>riial coiiilylo to the oiitor 
.side of the pisiform lioiic. Tlif upper third, which is deeply placed 
lienoath the Kii|ierli('ial jinmp of flexors, may lie marked out hy a line 
curvin;; sli;.'htly inwards fiom the hifiircation of the brachial to the 
jtniotion of the upper and middle thirds of the ahove-mentioned line. 

Guide. The above line and, in the lower third, the outer border of 
the flexor carpi ulnaris. 

Relalims in forearm. 

In Front 
Skin ; s..^ .licial and deep fa.scia. 
Branches of internal cutaneous, ulnar cuta- 
neous nerve, and anterior ulnar vein. 
Median nerve. 
Pnuiator radii teres. 
Flexor carpi radialis. 
I'almuris longus. 
Flexor digitoruni sublimis. 

Oillsitlc hisidr 
Flexor ilifiitorum sublimis Fle.xor carpi iilnaris. 

(in lower two-thirds). Ulnar ner\'c. 

Vein. Vein. 

Ulnar arterj' 
in forearm. 


Brachialis anticus. 

Flexor profundus digitorum. 

Anterior animlar ligament. 
Indicftlion.s. These are the .same as for the radial. 
Ligature in the lower third of the forearm (Fig. Position of the 
hand supinated and not too strongly dorsiflexed, to begin with. An 
incision, commencing just above the pisiform bone, and two inche.-^ 
long is made, lightly at first, along the outer border of the flexor carpi 
ulnaris. the superficial vein.s avoided, and the deep fascia opened. 

The wrist is then flexed, the flexor carpi ulnaris drawn gently inwards, 
the veins separated from the artery if possible, and the ligature passed 
from within outwards away from the nerve. Care is to be taken to 
avoid opening the sheaths of the tendons. 

Licatore in Uw middle third * of the forearm (Fig. 69). The position 
of the limb being as before, an incision, quite three inches long in a 
mu.scular arm, is made in the above-given line of the arterv over its 
middle third. Any superficial veins having been drawn aside or secured 
with double ligatures, and the wound wiped dry, a white line, which 
indicates the intermuscular septum between the flexor carpi ulnaris 
and the flexor sublimis, is looked for. If the incision is not directly 

* Tho iirti ry is cmly lijiutiiicd in its ii|)jht third f(ir woiiiuls ; it is ncicssarv to rc- 
mcmUr llie couisu of thu vesBul — ubiique from without iuwurds — and to divide Hutiicii-ntly 
tile saperficial flexon which lie OTer it. 



Fill. MS. I.ifjaturi' of the ulnar artery uImivu thv wrint. 'I'lir priK'«'»8 of 
deep fucM given off frum tho ticxur Mr|>i ulnam luw licrn opened mwl drawn 
■aide, expoaing tlio ulnar vcawb, with the nervo lying internal to them. 

Fib. V9. Ligature of the ulnar artery in the middle of the forearm. TSe 
flexor oarfH ulnaris internally, and the flexor sublimit externally, hare b '\ 
drawn arfde. The ulnar vessel.a. nerve, and part of tho RexM ^oloBdiui ar 
lecn at the bottom of the wound. 



ovtT tills, till' filL'<'s iif till' Mipri til ill! Wdiiiiil may lie carffullv clfun-d 

u little to Dili' >ii|i' or tl llicr till the .>*c|ituiii is found, or. with the 

fiii(r«'i-ti|». the .siilius iM'twci-ii the ulxivt* iiiuwIoH may ho wtuj.'ht for. 
The (lf<>|) fam tu havitt(; bopii slit up tn the full length of the wouml, a 
inuMCular branch, wliii li will nerve an a guide tn the artery, will uften 
be f«nind rominj.' up in the ititertrmwtilnr «|inre. The relhilar tissue 
here Iiavini.' Iieen (.irelnllx- lom llii(ini:h. the iimscles are relaxed hy 
heiidiii;; the wrist ;iiiii elhow ; retractors are now intnidiiced well into 
the wound, this wiped dry. and the artery jooki'd for. The nerve, 
which lies to tlie inner side, and juiim the artery at the junction of the 
middle and nppei thirds of the forearm, may Ik< wen first. The artery 
iH'ing deaiieil. and the vena> coniiten separated fn>in it if [MHwible, the 
ligature is pasRed from within outwards. 

This is the only lif.Mtiire in the lorearni wliicii will ^'ive tronlije in 
the dead suliject. owinj; to the depth of thi' xcssel. and sometimes tin- 
dilhcnlty of hittin<; off the inlermust iilar septum. I?ein;,' fir(|iienl|y 
.set as an e.\amination-test. the operation shoulfl lie can luily studied 
by those at work on the deatl body. 

DilBenltiM and mistakes. ( I ) Depth of the vessel in a well-developcil 
limb. (2) Making the incision too short, or too much to the inner or 
outer si(h'. and thus flndinir a wronj: septum. » .(/. one lietwceii the tle.\or 
carpi uliiaris Miid the He.xor profundus, or that lietweeii tiie lle.\or sui)liniis 
an<l tile pahnaris Ioiil'us. 

Aids. (I) Keepini; carefully to the above-given line, (2) Hitting 
off the ri;.'lit intermusi iilar .septum and corresponding sulcus. (-'J) Finding 
a muscular branch, and using it as a guide to the artery. 

If a WTong sjiace is nnich opened up in the living subject the con- 
tiguous muscles should be liroiiLrlit lou'eflier with sterilised sutures cut 
short, due drainage being provided, if needful. 


Indications ( I ) Xi-w grow ths. esjieciully myeloid sarcoma. (J) Tuber- 
culous osteitis, e.ij. of the lower end of the radius, caseating. and resisting 

Operation tor Removal of ths Radios. This is the bone of the forearm 

in W'hicii Mivi loid sarcomata more commonlv o!i;.'inat('. The followinj; 
is taken from a most successful use by .sijr H. .Morris.' ii, which he 
removed the radius and ulna extensively, for a myeloid growth originating 
in the former. becomiiiL' firmly attaclie l to the ulna. 

A long iiu'iKion was niutlc over the outir side of the ivuini.>. from the .-.lyloiil 
i)rocof« to the upiier third. The radial nerve was uwd as a giiitle to the intmal 
between the supinator longus and e.xteiisor carpi mdialis longior, Sir H. Morris 
having found on the dead siihjeet he could ai<>st readily separato tfie soft 
structures from the front and Vwick of the radius liy goiiij. Ix-twVen thow muscles, 
iiiid keeping tlie supinntor to the fore part of im isiua, Tlic supinator loiigus 
iind ]ironator tores their iii.sertions having lieeii ileta(li<<l frmn llie radius, the 
lione, wlieii freed of its iiiusch's in front an<l Ijehiiid \>,is s:i«ii ihrouuli at tlie lower 
edgi of tlie supinator hrevis. A sediud lor 'itmiiiial uieisii.a of h'ss extent than the 
first was made along the inner side of the ihia from th( urist juiui upwanls. and 

thriuigii ii the n -T iif thi s.,ft ].„ll> ,i I'l,,,,. lli. I.oi i iiiii.i. lioue 

Wi! .'^awn lietween three and (our iiiclu > .diove the wii t. ami the lower ends of lioth 
hones disarticulated hy op, nini; the wiist-juiril m: the iiuier side. The entire 
tumour, with the ulna and pronator cjiiadratus, was then removed tit viasm. Four 

* Clin. Sor, Tram., vol. x, p. 138. 


v. ai- IhI. t Sir II. Morrw l.nmnht Km- | iit bi-lon- fh.- ninUnl Sm-M-ly.' Th«-r.' 

■««H no ri-cum-iiw. By the aid ol » K-uiIht .(.liiit th.- |KitN|tit «.y .il-l.- t" iiurn . 

.lr.-«.. riirry, ami wank Micl «M« tot her chiWrt ii. -I- 1'", « 

Ullerly. lonce cantnoUan bad Uken pUice, ahc i-oukl Itokl Iwr Imiul out i.lriunlil 

without any support. 

Thf lute Mr. Cluttitn n-porlfil thn-e iiistriHtiv.- rasos nf . lulMstiMl 

wTcoma of the tadiiu.* Tw f the cuwh afT.'i l.-.l thf low. r i-m.I ot th.' 

bone. In orie not only the lower en«l of tho radiiLx (tli.- (li.s."a.s.Ml l.-.n--). I.iir 

tliat (.f th.' uliia also \va« rt-m<>v<Hl.» " so that the hand might hi- left in 

ii Hfiaiiiht hii." with th.' forearm." The result of tbU itep was timt. 

whih" th.' linih w is u.s.'ful m th.- |.atii'iit".s (M'cupation— that of a painter 
a.s h.iin an h.' wore a l.'atluT gauntlet, withfMit this aid he roui.l <lo 

nothing. Kxumination of th.- spfciinon show.'.l that th.' ulna was i|iiit.' 

free. In the necond case. als<» of the lower end of the radius. aiiiiiufatioM 

was performed, as the growth was thought to be panwteal ..r 
K.xaniinaticm of the specimen showed that it was endosteal, and .Mr. 

( lilt ton allowed that a free incision might have shown that miection 

ami .saviiifi the hand were possili' Tli.' third was a mveldd growth 
of the upper end, head and ii.'tk of the radius. 

This was successfully removed bv an incision on i side <>ver 

the most prominent part of the tumour, '■ the radius being divide. I an 
inch below the growth." This patient died, eighteen months iat.-r, 
of renal present before the operation. No recurrence took place 
in aiiv of the three cases. . i u tv 

Slowness of growth and regularitv of expansion of the bone are tbe 
most important guides in the dia^rnosis of endosteal from periosteal 
sariomata. Crackling and pulsation are also very valuable, if pr.'s.'iit. 
Skiagraphy will also help. The first tw.> were absent m all .Mr ( luttoii s 
ca.se8. and it is noteworthy that, while the growth which;d tli.' 
upper end of the radius appeared to be exceedingly hard and i- sist int, 
as if entirelv bonv, it turned out to be soft, almost cUffluent. A Ir. .- 
exploratorv incision is the only reliable guide,* as it is certain that the 
malignancy of endosteal .sarcomata varies within wide limits, some 
growing slowlv and evenlv inside th.' bone, .)thers perforating it m one 
or more places. In such cases, after resection, the patient shouM I)-- 
watched carefully and for several years. 

Operation lor Partial Eemoval ol th* Ulna. In the very much rar. r 
cases of myeloid tumours springing from the ulna, the following may 
be the course adopted. The account is taken from a paper by Mr. I .ucas. • 

A longitudinal inciwon, about four iiich.'s long. L'xpo.^c.l the tuinour i«v. ii 
the flexorand extensor carpi ulnaris. lu making this tlu' d-.r-sal brm> . of t li.- iilnn 
lUTVc was divided. The soft parts having bf. ii next r. tra. t.;< . llw Im.m,- »,.s . x^ 

I.o:*ed above the level of tho tumour ami sawn thr.iu«h. Ih.' pi'^.- ■ i'<>"<' 

with the tumour was next drawn out of the wouiid, while the uUeros»cou» niljranc 
was divided, uid tho ext«w» indicis on the posterior, and tlie pronator quadratus 

» Trans, vol. xiii, p. 156, pi. vi. 

2 C;»n. Soc. Tra n«., vol. XX vU, p. 80. , . , , ni ,,,„.,! 

3 Thi.-. s<tep is not to he recoinm.'ii.l.M. Only th.' l.uiic alTc tcl shoiiM \>r r. n,„ , ,i ral .lisnlac.'i.u-nt ..f thi' han.l will f»ll..«. Lxt it will not !«■ a ll .il. a.i.l. an , .mtnu l ... . 
tiik.'-. place, th.' han.l will rapidlv gain st,. nj^th, and ii.,, ru.i.niiii« li'-.iii' rit, 

"'"< Ynvolviment of the soft ts. especially when these are coraplic»t4.<l an.i 
deal with, as in the case of those around the head of tte Ubia a» wMwpared with th.-^ arounu 
the lower extremity of the ladtus. and the ext<»«4ve imptoaUon ol the uk-Iuh «. wui 
be the chief indication for amputation 
» Clin. See. Tran»., vol. x, p. T" 



on the untcrior. si ]mriil( d from the tumour. Thf removal wub completwl by dividing 
the ligameiilN of the lower radio ulnar jwnt. the iitttuhnu-nt of the triangular fibro- 
curtilage to the ulna, anil the intemnl lateral ligoment. The imf'ent left the hoxpital 
in five weeks, the resulting U!<efulness being j'xeellent. 

Further reuihrks til the treatment of myeloid growths will be found 
in the Surgery of the Lower Extremity, when those affecting the head 
of the tibia are considered iq.i'.). 

Excision of the Radius and Ulna in Military Surgery. By this is meant 
deliberate n inoval of portions of these bones daniajr«'(i by <:iiiis|iot or 
other injuries, not the mere pickiiif! away of spi<'nl('s and Irajinients. 
Experience gaiiifd in the St)uth African War shows that this mode of 
treatment will be but rarely called for. Lieutenant-Colonel Hiikson' 
collected sixty cases of gunshot fractures of the bones of the forearm, 
none of which terminated fatallj', though six required amputation. 
The number is made up of injuries to both radius and ulna, fifteen ; 
of the radius alone. twciity-se\ en ; of the ulna alone. ei<rliteen. Takinj^ 
the rcfjulation Mau.ser bullet as the standard, the varieties of wounds 
raufied within very wide limits, from e.xtrcine sliatterinj; and pulverisa- 
tion to simple perforation without solution of continuity. The former, 
involving the shafts and oft<?n associated with extensive laceration of 
soft parts, were usually septic ; the latter, usually involving the extremities 
which are largely composed of cancellous tissue, often escaped infection 
and healed readily. Colonel Hickson sums up the treatment of these 
injuries as follows : 

" The most important measure in the treatment of all gunshot injuries of bones, 
whatever their nature and position, is the prevention of sejif ie ohanges in the wounds. 
It is the occurrence of suppuration that threatens life and neeesitates ain[>utation 
in the vast majority of cases requiring that oiK-ratinn. K\er>-tliing else sinks into 
insigniticancelK'sideit,andafraetureiires<'nlingthelii>;lii'>' dcgiee of comminution is. 
if aseptic, of less moment than a trivial ipiie in wliicli .--ii|i|)nratic)n lias occurred. 
Not oidy does suppuration cause <1< lay in union and lead to m c rosis. Imt it is oidy 
too often the precursor of septic osteomyelitis and general scptica inia. I'li- 
fortunately, owing to the conditions attendant on .service in the tield. siippination 
occurs in a considerable nunilnT of coniniinutcd fractures. . . . On the snl'ii et of the 
advi.sability of exploring comminuted fracture ami n iiioviiij; loose fia^riuents. 
dillcreiices of opinion seem to exi~t. Some surgeon* are strongly o]H)Osed to this 
practice, and others as tirinly convinced of its nccc-sity. The truth seeuLs to lie 
between the two extremes. If the fracture be septic and highly comminuti-d, the 
exit wound should be explored and all loose fragments removed. It is useless and 
dangerous to leave them in »itu. Should the fracture be aseptic and badly com- 
minuted, fragments of bone, separated from their attachments and lying loose in 
the surrounding tissues, should also, I think, be removed with the most careful 
aseptic precautions. If the fractture be aseptic, the comminution not very severe, 
and the fragments not much displaced, nothing is to be gained by interference, and 
harm may result."' 

The advantages of treatment on the above lines over the excision 
of portions of the injured bone, as practised in former days, tire well 
seen by contrasting with the above the followiiij; remarks by Dr. Otis : ^ 

"Of this large number of excisions in the continuity of the lorearni there is 
little to remark save that, in the aggregate, the mortality of shot fractures appears 
to liave been sensibly augmented by oiK^rative interft renee. and that I have sought 
in vain for a single instance in which a formal excision of a portion of the shaft of 
cither radius or uhia had a really satisfactory result as regards the functional utility 
of the limb. . . . The cases are' divided into three groups: (1) primary ; (2) inter- 

■ JU^. on Siuf. Cmm noM in the iSovM A/mon War, edited by 8urg.>Gan. Ste|A«moa. 
* Med,andauft. Ui*t.ofAe Warojtke ArW/ ii, p. g35,e(«i>}. 


moditto- (before the thirtieth day), and Bocondary (after the 

th< prhnary 10 ixr ei-nt.. and of the interm.Hllary 19 per eent. end.-,l fatal > . the 

,,u,r{!"i"y of the Womlary wan nearly a» high .u. that of the primary vx»m>m. 

Operative Treatment ol Volkmann i Contraction (Ischsemic Paralysis). 

This < MS a lule occura in thr forearm, though m raiv .as.-s it 
„mv allVct the l.mer extreinitv. It usually «K>c»rs in ohiMrei. and 
..enerallv. tlmuv-h l.v mo .neans always, follows the application of bam aKP« 
or sniiiits espe<iallv for such injuries as fia.tures of the horn's of the 
forearm or the lower en.l of the Imn.erus. ..r for separation of the ..wer 
epiphysis of the latter In many eases there can l.e no .loul.t 
that the haiulapos have been too ti(?htly applie.l or that he splmts 
have been allowcl to remain too long Ulu hanjie.l. llum>?h the sevent> 
„| the . ontrartion varies, the deformity in a tvpi. al case m characteristic 
The f..rearm is tirmiv tixe.l i., a position of full pronatiim, the wnst is 
Heve.l. tiie proximal phaiai.-es are hyper.xten.le.l. while the second 
and third an, fullv flexed. Th..ut:h the path.-h.^'v of the eon. it.on h 
not .iiiite clear, it is certainly due to interfere,..-.- with tiu- sup . 
of the affected muscles. The diminisl.e.l supply of oxy-.-n pr..l.a . > 
l.,„ls t.. a ...amilatioM of the c.mtractile substance analogous t.. th.| 

, han ..rurrin^ it. ri^or mortis, and followed by hbroid change an.l 

.•outnu tion. The .l.-formitv .l."V..|ops in about four to six weeks after 
th." injurv.' .lis.uss.-s fully the pathoh.gv. causatum. 
and tr.'atin.'ut. in a i.ap.T on Hl7 eolle.'te.l eas.'s.- 

When the deformitv is but slight, gradual of ti u. 
(■ontracti(ms mav be tried, combineil with massage and eleetru al ti.Mt- 
nuM.t 1 n S.-V.MV . a.s.-s these measures are useless : some form of opera- 
tive t.vatm.-nt is r.-.|uiiv.l. The following methmis may be employed : 
(1) ten.h.n-l..ngth.-niL'; (-') r.-se.-ti.m ..f l...nes ; freeing nerves; 
(4) my..ton.y. In so.n.- cas.'s a e..nil.ination of two or more of these Miav lie d.'sirable. , . .i ■ 

(1) Tendim-kmithmin,,. The ..f t.-n.lon-length.Mnng a l 
descrilHvl at p. !•?>'. Owing to the number of t.Muh.ns t.. d.-alt with 
1 opl.rali..-. is |o„. a,.l tedious. Mr. Barnard > has fully repmted 
two tre.ite.l in this way. 

In the first the imti.'ut. i.l. lit. Im.l tr.'at.'.l t''>r ^' fi^' tui- ..f U>^\^ "f 
the ri Ut f.,.^^^^^^^ ' t he s,.ln.ts were re.-lj,,.-., .! a, th.. . m.I o a «-. k. a ...vssure^ 
was o .... th.- f.....t .,f th. f,.na,„.. .\ lat.-.- the '2.' » 

». ix.'.l a.i.l six «.'.'ks aft. r th.' f.a. l.nv. the ha.i.l was ... th- p...s.t...n ..f mmn m 

'-IW was .I...i..i.e anas,h..sia. hut -.•-."t-V tao™.^^^^ 
in thr 1. .M.I an.l wiist. < In.-iat i\ .■ iat. rf.f. mv was .l.-lay.-.l l.> th h.aliiiK .>t tm 
„ ;:" ,. a„.l a «hi,l..Iv .m the tip -f the .i^ht in^-x filiger 
,„ i„i,MV an i.,. isi..n was n.a.l.- al-.i^ the for.-arm. skiu-flaF V U 

„ , ns thi. k. r than st,„il t«ine, Hnlit for one .«ul a half ....'h.'s the 
Iv , ! . h. • an.l 1..1..W. .... o|.|».Hite siden. The ting.Ts were then exten.l. . . 
; ! ;,,.;,;:, l',lv,.s ,.f the divided U-J^U aUowed ... sli.l,. upon .■aj^. '>'.^- 
as was n...-ssa.y.a...l then united with one or two s.u.mvs >.e >. k " " 
„f ,1,.. ,l..xor pr;.fun.luH digitorum w.-re so l.leM.lo. an.l a.lh.'.v-.t , 

C.^ «aVstranaely bUHKlleM... The muHck>H. where exponed, were pale. tirm. dry 

^ s:;';:(:;^1:;rH;v ll. 'K^!!'A?^H„.leron theTreatment of Volknmnn'. ('ontrae. 
tion. .1 « H<iU of l^Mnifril- vol- Ivii, I»i3. p. iWiJ. 
3 Lniinl. vol. i. imtl. p. 1138. 


and fibrous. Tho limb was put up on a back-sdint with the fingOT fully extended 
Healing tcik place by first intention. A fortnight after the opmtion, maMWge ana 

passive movements were l)egtm. , , , i „, 

Tlie second ease was a bov :rt. 4. whose forearm had been severely crashed 
with much etiuiuon of Mood, but without fra.ture. The '''"'^^fP'''':'''' 
external angular splint. «n<l light baiulaging employed. Hive weeks la . r the trouble 
becan to appear. At the o,K.ration the Hexor tendons were treated as described 
above but th( pionators were not interf.Ted with. Improvement after four moatbs 
was so marked that the mother wished something done for the loss of rotation of the 
fr)rcarm The insertion of the pronator radii terea was exposed and the radial vessels 
and nerve .separated fromit. The muscle was then split and divided on opixwite sides 
as the tiexor tendons had been. As sujanation was still imperfect, an incision was 
made over the lowest part of the ulna, between the extensor and Hexor carpi iilnaris. 
The pronator quadratus was separated with a periosteal elevator from the ulna. 
The pronator radii teres was th< n sutured in the upper pMt of the wound, itie 
forearm could now be fully supinated c" a splint. , . ^„i. 

Five to eight months after opemuon both children could grasp a stick or I»CK 
up a pin : neither could make a tist. but both cases vere steadily improving. 

(2) lirscctio)! of honcii. Ill this im'thod. portions of the radius and 
ulna are e.xcist'il. the sliortcMiiiifi of the forearm thus obtained allowing; 
the wrist and lingers to be straightened without interfering with tlie 
tendons. Mr. R. P. Rowlands" describes a case in which he employed 
this nietliod. jiiving interesting operative details. 

The patient a girl a t. (i. h id six months before admission a fracture of the ratlius 
an<l ulna near tlic middle of their shafts. The arm was nui< h bruised and swollen 
Is foie si)lints were applied. The skin sloughed in three jilares. \Vhcn f*en the 
ilefonnit v was severe and ipiite t vpical. .\n in( ision was made along the middle third 
ol 111, radial border of the forearm. The tendon of the extensor caqn radialis longior 
and I iie ladial nerve were drawn forwards and the extensor carpi radialis longior was 
n tracted in the opposite direction. This gave an excellent \new of the mwrtion ot 
the pronator radii teres and the outer surface of the radius as far as tlie extensor 
ossis metacarpi iwUicis, where the latter posses obliquely forwards across the iKine. 
At the lower end of the wound the upper fibres of the pronator quadratus were also 
displayed. The radius having been cleared of soft parts was drilled at two p(>ints 
one aiid a quarter inches apart, and then a portion of it one and a quarter inches long 
was removed by means of a line saw. The piece removed extended from the ins.'r- 
tion of the pronator radii teres to the pronator quadratus. A similar iiortion of the 
nina wa-i removed through an inc ision along its subcutaneous border, but one inch 
hiphi r u ). The bones were united bv silver wire : the drill holes in tho radius were 
so direct '.l that wlien the wire was tightened the lower fragment of the radius was 
rotati'd into a position of seini-pronation. During the oiK-ration it was noticed 
that the deep tl. xors were lirni and liliioid. At the end of the Operation the wnst and 
ting. i s could be extended almost into a line with the forearm. Massage was com- 
menced t'w the ninth day and passive movements as soon as union occurred. 
W hen seen eightct-n months later the muscles of the forearm bad increased very con - 
siderablv and the limb had lost ite sunken appearance. The child < < i.M use the hand 
for most jiurposes and conW pick up a pin or a lieiiny with ease and rapidity. 
There wa^ a good range erf movement in the fingers, and a powerful grip. .Supinatioi , 
and pronation were well performed. 

The id vantages of this method are (I) that the operation is easier 
and shorter than tendon-lengtiiening. {•>) The radius cnn be (Iriiled 
in such a manner as to correct the crippling limitation ol supination. 
(.•{) The tendons are not interfered with. The chief disadvantage is 
that there is a possibility of non-union. 

(.'il Frceimj the nerves. Though a lesion of the nerves is not the 
tnuHc of the deformitv. vet secondary affection of the nerve-trunks 
from involvement in connective-tissue overgrowth is freiiucnt. Jenks 
Thomas « says : " Disturbance of sensation in the hand can only be 

' L<niM. ItK).-., vol. ii. p. 1168. * Loc. "uprti fil. 


,,,..1„<-.,1 tlm wav. ospecially when it » limited to fe ar^ ol skin 
'on. s„...,.lin.. t.. tlu. .listribution of one of the nerv^ of the am.. Tho 
s n e n tru.- of atrophv of tho small muscles of the hand, am 1 
pi^Lce of the roartiou of aoKo,unation in those mus.les ,8 
?lSce of involvement of the nerve-trunks. Paralvs.s of these hand 
miles ran only be due to ner^.. involvement and t - pon. .s <. < 
f. .,,>u.„tlv overlooked" In such cases considerable bonetit ma> ik 
U : .V affected nerve or nerves. Jenks Thon>as • nu-nn-nuj 

:' se in. l^.hTlHM.lnar nerve was freed dissected d^^^^^^ 
.ondvltr .m)ove and followe.l downwards through the flexoi (aip 
ari ft V s then transferre.l to a point anterior to *he in enml 
Zdvle the fascia being sntme.l In-neath it. leaving the between 
d ep asia and the' suheutaneou. fat. Though tins -as t l.e - v 
.peratiJ!. treatment, a marked mipm^ement followe.1 a d .s. x no I s 
1 ter then- was pood functional u«e of the hand ni ever> vsa> m sp t. 
; s i' sh.Htenin.' ..f the flexors. It U only fair to p<..nt out tha 
tLit -i^Hne. surgeon; have found freeing of the nerves a nmtter of great 
difficulty or even an impoBaialitjr. 

(Fi^. 60, 70. 71 and T.') 
This operation is frequently perfonned, u.iaily for 
I.ut o.rasiunallv for malignant growths or severe and intractable tttlMr 
cu' . or sei)tie tronbh' in the wrist or hand. » tt„„j 

. .U,at,„>,iral Poiuts. (u) Tho two bones are not fixed 1 ke 

i„ „ the log. but iiK.vablo. This rnobihtv may prevent the.r I.M. g 
lei when the knife is sent across in transtixion and thus lea.l to 
ration of the interosseous membrane : it must also be r. ni. inheie, 
,n snvin.' otf the bones. Lastly, on this m..bilitv in pn.nation and 

ipination the nsefulness of the stump. 
Set as lon'r as possible, the bones being always, when practieab e. 
^wn V below thJ insertion of tho pr-nator radii teres mto the nndd e 
S the outer .surface ..f tho ra.lins. If the bones be .luMled aho e 
i serti.... of the pronator teres, the radius w. i beeoine supn.a e.l , 
„,l,er rotation movements will be lost, (h) In the upper par t! 
„,.,,n in front and behind, are fleshy bellies; beU.w. tl o soft 
.,.e inerea.singlv tendinous. Furthermore, the anterior border 
.adins and the posterior of the ulna, especially tlie latter, are 


(if tlie radius and tli 

'"^TlJe'teis'^ilSr the forearm an unsuitable locality for amputa- 
tion bv the circular method. , i.,»..,..d with 

Different methods. (1) Skin flaps, antoro-postonor or latoial, nm . 
..innl!, inis^n of nn.seles, &o. \,) Modified circular method with 
,„,„al anterior and posterior flaps. Transfixion flaps. 

MuJies dr. (Figs 70 and 71). While in an amputation so ..ften 
ca W for it is well to practise .several methods, none, on the wholo. 
^'"uMs L wdl as this. 'for the following reasons : («) By -^t 
flap a little longer than the other, sufficient skm can always bo obtain . I 
to give a good stump, (b) Transtixion, while quite unsniied to the 
. S.-o«»«oa|miK.rbyJonk.ThoM.«on;- Nerve movement in tl.. I«. l.a >n„ l-.ralysis 
nf Volkinann. • AnnaU Surgtrf, vd. xhx. 1909, p. 389. 


lowor third, owing to the miinoious tendons, can only be performed 
in the upper third in nicMU'ratelv muscular forearms with nltnnate 
satisfaction. For in a bulkv. fleshv limb (as in a case of accident in a 
male adult) it is n .t . as\ alwavs to cut the skin longer than the muscles 
in brintrinj; out thf knit.', and so to prevent the tendency of the fleshy 
heilies 7o piofnul-- wliilr tli.> (laps are lMMn<j; united : and a little later, 
tii.'se inu.scles. witli laru'i' siirl'a<es cut ob]ii|iiely. fjive rise to a j;ood 

,l,.a] of 1)1 l-st'iined oozing', which i-, very iikclv to cause tension. The 

brachial havinji been controlled by a tourni.piet. the arm e.xfended 
from the side, with the forearm pronate<l and the hand steadied by an 
a.'ssistant, the surgeon, standing outside the limb on the right, and 

Fi«i. 70. 

inside it in the case of the left side, places his left index and thumb 
iin the bold. 'IS of t'l.' la.liiis and ulna, at the spot where he intends 
to saw th.' Tli.' point of a. nairow-bladed knife (about four 
inches Ioiil'I is th.'ii in.MTt.'.l just Ih'Iow th.' in.l.'x. carried alonj; the 
bone for tFiiv.' inches, th.'ii ciirve.l suddenly across, .so as to mark out 
a bioa.lly iiiclii'd. not a pointed, flap (Fig. 70). an.l tinaily carried 
up along the biuie near<>8t to the surgeon to a point just below the 

This flap is th.Mi diss.'ct.'.l up. of .skin and fascia, and of 
even thickness tlir.iui.'hout.' Th.' foivarm is ue.xt raised by the assistant 
holdiii".' th.' han.l. .so that its palmar aspect fac.'s the surgeon.- who 
marks .lut. bv a curved cut joining the two horns of th.' other inci.sion. 
a similar Hap on the anterior surface, but one .)nly about two inches 
in length. This flap having been raised and both retracted, the .soft 
parts are divided with a circular sweep close to the base of the flaps, 
this li.'inj; repeat. -.1 once or twici' till t!ie bones are .piite exposed. The 
knife is th.'u with ilue care of the .severed arteries, between the 
bones, so as to divide th.' int.''oiis membrane, and th.> periosteum 
next cut circulailv wh.'!" th-' s.iw js to Jiass. The bones are sawn 

' Thf I Mirfiii .' of 1. I all.-d >kiii tliii> kIuhiI.I alwiiys. wlicn ik.s.m1>K', .sIidw a few 
nui« iiliii > : >h.>ws that tlu' d.i-p fascia U present, in which (he VMseU run 
from wliit'li brauclii s \miui to tlu- »kiii, 

» I'ftws must be taken to k«-p the Umvn {Mrallel. now, and throughout the operation. 



throiifjh. witli the followiiifi ])m autioiis : Tlif liccl of tlio saw hating 
been placed on tlic liones. it is (liawii li;;litly. I.iit liiinly. towards tin" 
operator two or thrt-e times, so as to make a <;i-.)ove. Witli a s.-ries of 
light sweeps, in which the whole length of tlie saw is used, tlie two bones 
are then cat through together, the limb being kept snpniate.l durnig the 
use of the saw. so as to keep the bones as parallel as possible. 

Tlie a.ssi.stant in chaise of the lower part of the limb must be most 
careful to IimM it ; if he depress at all. the bones will certainly 
splinter V, :un half sawn 
through; if, on the other 
hand, he raise- the parts 
the saw will be locked. Any 
tendons rccjuiring it are then 
trinnned. nerves cut short 
and S(piare. and the vessels 
ligatured or twisted. There 
are usually four, viz. the 
radial, under cover of the 
sui>inator longus, ch)8c to 
its bone ; the ulnar, covered 

by the lle.vor carpi ulnaris, 
on the front of the ulna. 
Their respective nerves 

are good guides to the 

arteries, save quite low 

down, when the radial has 

gone to the back of the 

lind). The anterior inter 

osseous is fouml on the 

front of the inteiosseous 

membrane, and the i)os 

tenor interosseous between 

the deep and superficial 


If the surgeon prefer it. 

instead of having the fore 

arm raised so as to face 

him (Fig. 71) while he 

shapes the flap from the ■ , ^ . i . i 

anterior or fle.xor surface, he will tell the assistant to completel> 

supinate the forearm, and proceed to make the flap with the limb m 

this position. . , » j 

If. owing to the condition of the soft parts, lateral flaps are i)referred. 
the Hmb having been pronated. the surg.'on marks tli.' site ol bone- 
section with his left forefinger and thumb placed on the centre ot the 
extensor and flexor aspects of the limb at this level lien, looking 
over the forearm, he enters his knife in the middle of the le.xor surface, 
and carries it, cutting a broadlv arched flap, about two and a half inches 
long to a corresponding point on the centre of the back of the limb, 
and then from this point down aaain over the side nearest to him. to 
the spot where the knife was first entered. The Haps are next liisseet.-d 
up with the precautions already given, and the operation completed as 

Fir.. 71. 


(2) 'Modified Circular Method with equal Anterior and Posterior Hups. 
Tn this method the anterior-posterior Haps beinj; of (Miual l.-iifith s.'ldoin 
have to be more than one and a half inches lonj,'. the boii.-s can be (hvid.-d 
at a lower level than any other, and thus the largest possible stump is 

AVhile the scar lies directly over the ends of the bones, this will, 
under most circumstances, be the point where there is least friction, 
because the pressure of an artificial limb must fall either upon its anterior 
or posterior aspect, and not upon the end of it, as is the case in the 
lower extremity. Should, however, the occupation of the patient 

Fio. 72. 

involv.' pushing, it. is difficult to see how the face of the stump and the 
scar will escape pressure. 

'I'll.' liiul) being abducted and fullv supinated. the surgeon standing 
to the light of the limb places his left forefinger and timmb on either 
side of the limb at the point proposed for division of the bones. 1 In- 
knife is then entered about half an inch below one of these points, and 
is made to trace a short anterior flap terminating at a correspoiuliug 
point on the opposite side. When this is done a similar posterior flap 
is marked out. In a forearm of ordinary «ae the lower hmit of the 
flaps will be about one and a half inches below the seat of circular di\-ision 
of the muscles, and tins again about one and a half inches from the 
point of section of the bones. The periosteum is divided cleanly right 
round the bones and stripped up with a rugine, together with the muscles. 
This provides a cap of periosteum for the cut ends of the bones and a 
nicely rounded end lor them, and in the forearm guards against a fusion 
of the cut ends, which would cause a loss of pronation and supination. 

The nmsclcs should never be first stripped off <iie penosteum, and 
the latter then separated from the bones. 


VM IminiUitinn of fhr Fommn h,, Tmmfixinn Flops (Ki>j. 72). In 
the .4;. ..fa nm-l.Tutely ,nus. ular (..roaini tlu- s.n^.M.n nmy ...akc U8e 
of this inethml in amputating tl.r..ugl. tl.c nu.M of tlu- for.arn,. F. r 

tnln already give,\ («r p. tH). .notinui ,s -'^ -;>-;;;;;; ; 

l.ut the rapiditv with which it can be done at., the lu.tu. 
„f tliose mav have to treat wounde«l m war on a large seal.- j.r 
i„ railwav f.cci.lents where more than limb r.'.,uir.>s amputation J he 
li„,l, being abduete.1. an-l the forearm snpp..rted an.l pr.>nat..l. w. h 

e bones as parallel as possible, the surgeon, stan.lmg ..utsu c the right 
1^ iiiide the left limb' lifts up the soft parts at t u- ^^I-.t where he 
intends to saw the bones, an.l sends a narrow-bla.led kn,!. I u. t. 
live incheg long) across the limb, entcrmg it and bringn.g 't ou st 
ab..v.> the bon<^. He then, by cutting downwards and fonvar. s. sl.a .. s 
as broa.l a flap as p..ssible with a steady sawing movement, taking lart. 
ief re bringing ..ut the knife cut the skin longer than he muscles 
bv Jontinufng th.. of the Knife after tlu« latter are felt to be cut 

rough. The flip should be thr.>e to f..ur .nches according to 
throindition of the tissues ..n the other si.le. .-a. h lap bemg made as 
broad as possible and bluntly rounded as it is tnush.'.l. 

The tSues on the front are then lifte.l from the b.,n.>s an.l t.ans- 
lixe.l bv passing the knife across immediately above the bones at tht^ 
base of the lirst-nui.le flap, the limb being now supmate<l As in tins 
ion.l translixi..n the stin on the farther s le .,f the 1^ 
punctured, it is w.'U f..r tlu- snrg.-on tu hol.l down its cut .-.Ige with a 

""The second flap is then cut, br.)ad, well-r..unded. an.l tw.. an.l a half 
to tliree inches long, according to the length of the anterior. 

In making either Hap. while the muscles are bemg severed, the wrist 
should be kept flexed. The flaps are then retracted, the s.ift parts 
severed with a circular sweep, the inteross.-ous nu'mbran.; divided, and 
TZ Tst of the operation completed as in the m.-th...l i.rst descnbed 
If thS method is used, the nVrves shou'. l always be cut short and 
square ; otherwise painful, bulbous ends may follow. . 

\ verv rapid and effective modification of the is the foUowmg . 
\s *owin;' to the ine.,ualitv ..f the soft parts on the back as compared 
with those on the fn.nt of the f...Tarm. and also from the proximity of 
the ulna to the surface her... translixi,.., ..1 a .L.isal flap is not always 
easv, a quicker method is as f.>ll..wH : A skin tlap. thiv an.l a half in.-he 
long, broad, and well r..un.le,l. being mark.'.l ..ut on th.- posterior asijee 
of the limb, the knife is immediately, without being taken ..If. pushe.l in front of the bones and made to cut a flap bv translixion. 
tw.. ami a half inelu-s the skin Wing cut h.nger than the muscles 
(vidempra). The dorsal skin Hap is then dissected up. the Haps retracted, 
and the bones clwired as before. 



AMnrXAflOl AT TBI ILBOW-70IMT (Figs. 73. 74. and 75) 

This operation pives excellent results, pood flaps being obtainable from 
the thick soft parts in front and from the skin behind, which is well 
uaed to pressure. It has not been performed so often as it might liave 
been, owing perhaps to the fact that disarticulation, however simple, 
is corwidered by some to be inferior to an amputation ; and because, 
owinc to the expanded end of the humerus, the flaps required are some- 
what larger than in amputation through the lower third of the humerua. 
Xew prowths of the bones of the forearm and, occanonally, severe 
crushes are the chief indications. , , „ • , 

Practical points, (a) The internal condyle is nearly half an inch 
below the level of the external, (b) The joint is opened most easily 
on the outer side, where the head of the radius is the best guide. 
(c) There are thick maases of muscles on the front and sides ; of the 
latter those on the outer side (owing to the presence of the supinator 
longus) retract more powerfully than those on the inner, (rf) The skin 
at the back of the joint is well used to pressure, and is connected by 
fibrous bands to the back of the ulna. 

Methods. Owing to the va.scularity of the parts many methods 
may be employed. The first three are especially reconunended. ( 1) A 
large antero-internal flap and a short postero external one. (2) Long 
anterior and short posterior flaps. (:$) By a single lateral flap. 

The condition of the .soft parts mav render it desirable to employ 
one of the following : (4) Circular method. (5) Long posterior flap. 
(6) Long anterior flap. 

(1) AmpuMion by a large Anlero- Internal and a short Postero- Lsteriial 
Flap. The elbow is slightly flexed, and the antero-internal flap is first cut. 
The incision begins at the centre of the bend of the elbow and is continued 
down parallel with the long axis of the humerus for about three inches ; 
with the arm flexed to an angle of 135 degrees the incision will meet the 
inner border of the forearm at about this point. The incision is then 
carved backwards and upwards to the olecranon to mark out a rect- 
angular flap with rounded angles. .\ somewhat similar Hap is next cut 
from the external surface, but this should only be about one inch long. 
The soft parts are taken up with the flaps right down to the bone Any 
remaining structures in front are severed, the joint is opened preferably 
on the outer side between the head of the radius and the capitellum. 
and the forearm is then removed by dividing the lateral ligaments and 
the triceps. 

^ 142 


(2) Low, .inlrrlnr short Porterior F/«/w (Fi^'s. T:» «ml 74). Tlim 
„,oth.Hl .'iVs an . x.-ll.M.t .•..v. rinf: to th. front of the hun«TU«. ttUo«H 
T^y drainaj?.. u.ul ,.ns.-. v. s skin wImU i« well u-ed to l«m.wn.. 

Fio. 73. Amputation throngh the ^'I«7-if!°'i. 

Tl.e brachial l.cinfz controllwl a».ovc its centre the forearm l.on.}. held 
trinner 8 de in the case of the left, and outside the right hmb, raises 

the «r,ft parts in front of the elbow triangle, and sends his kn.l.- laid 
„.riz<.ntallv. across, just in front ..f the joint. Thus enterin-j .1 .me 
rrS^^^^^ interiml condyle, and bringing it out one and a half i.k^ 

Sw the extenua one. or iu» «f «. he cuts a well-rounded flap, three 


inches long, taking care, as tho knife emerges, tiiat the skm is cut lonjicr 
than the nmscles. Then. \Mm\\ft his knife behind the limb, ami looking 
over, the Huipon joins the two eiiils of the base of his first inciaiun by 
u convex cut tlirou;;h the skin over the buck of the olecranon, so as to 
mark out u fluj) un inch and ii Imll in length. This is raised without 
■coring, care being taken to keep the knife towards the uhia for fear 
of " button-holes." The joint is then opened and the forearm removed 
as described above. During thia stage the assistant in charge of the 
forearm* pulls this away from the arm. 

The 'brachial artery is then secured, together with any other vessels 
which continue to bleed on removal of the tourniquet. Any nervea 
which require it »ie cut short, drainage is provided, and the flaps care- 
fully united. 

Should the surgeon prefer to do so. the anterior flap may l.c cut 
from the suiiface instead of by transfixion. This course sliould be 
adopted in the case of a bulky, muscular limb. 

(3) :lmputulion by one Laternl Flap or hij Lateral Skin Fhps. The 
advantages of these methods are that they are very easily done, and 
that, if more skin is available on one side than on tlie other, flaps un- 
equal in length can readily be made. If the snrjreon amputate by 
lateral flaps standing as before, and havinjx his left index finger o 'he 
centre of the elbow -triangle and left thumb at the correspoiidinfj : iit 
behind, he looks over, and entering the knife close to his thund;, irks 
out, on the side furthest from him, a flap well rounded and ab ui, two 
and a half or three inches long, reaching to the finger in front. He 
then marks out a corresponding flap from this point, on the side 
nearest to him, to that where he began. These flaps are then dissected 
up of skin and fiiscia as thick as pt)ssible, the soft parts severed with 
a circular sweep, and disarticulation performed, beginnin<; at the outer 

(4) C'ircuUir Method. The su^on, standing as before, makes a 
circular incision round the forearm two and a half or three inches below 
the joint, f;oing throug' skin and fascia. A cut! of skin is then turiK'd 
hack as far up as the , int, the muscles severed with one or two fiiin 
sweeps, the lateral ligaments divided, and disarticulation performed as 
before. The edges of the wound may be united either horizontally or 
vertically from above downw^ards. 

Mr. A. G. Miller, of Edinburgh,^ sujasests the following modifica- 
tion : ' 

The Umb being held out quite straight, a circular incision is made one and s half 
inches below the condyles down to the dctp fascia. 'I'he skin on the anterior or 
flexor asiH'tt at once retracts considerably, making the line of iniision ol)li(|uc. 

The extensor tiaj) is now dissected up" as far as above tlic olecranon, care be ing 
taken to cut on the ck'cp fa,scia. and so to rctlcct tlic subc ulancoiis deep fascia, and 
its contained blood-vessels along witli the skin. The lla|> is loose and ample. Ijcing 
taken from a part where the skin is naturally redundant in order to accommodate 
itself to the normal action of flexion. After retiexion of this llap- practically the 
only one— disarticulation should be jK'rformcd from the front, it will then In- 
found that there is a long flap on the extensor and posterior asiK-ct, with i)raetically 
no flap uiKin the flexor aspect. After the l^wd-veasels are secured and the nerves 
cut short, this single flap folds nicely over the condyles, and is easily secured by 
sutures. I-uter, llie upi»earauti; of the stump is vcrj- sat isf acloiy. Much tissue 

» The Sroltlsk Medical iind SurijiditJoiirnal.iicfti. 1004. p. l',»3. 

' See a paper by Dr. A. C. Wood, of Philadelphia [A tiii. of Surg., vol. zUx, p. 101}in 
which ho records a case of sarcoma of the forearm treated in this way. 


M not n"|iiii. .l. Tl.r ..(« .alio., i-. 1 1,. n for.-. s.iital.l.- primary ami «wiv»«ry 

AiiipiiUitioii hy (.■») by a loiiji ixwti'rior Hu|> mvI a lonjs antorior 
tlip rwjuire no HiKH-ial dwtcription. 

Pnetieal pointi. Thww b«ir upon the HurrcsH of tliin miration. 
(I) It is a ...luparativ.'lv simple joint, with Hniall articuUr aurfai-ea 
na.lilv >'i>t at. (2) Its synovial nirrnbranc is simple. (3) Ita vaacular 
siipplv isalaimlint. (I) 'rii.' surr.Hin.linj; nnwl.'s are ixmerful. enMinng. 
if th.-v r.'>;aiii tirni attacliin.-iit. cxc-H.-iit mol.ilitv. From the ab«>ye 
ami from the nntowar.l elV.'.ts of ankylosis, a natural nire in th.- 
eUM»w in often nut no uwful uh that given by excisM.n. This opj-ration 
shoiiM be p.>rforniwl oftener, eapeciajly in the fifst mx of the folhiwing 
conilitiiiiis. ... • i 1 i t. 

Indications. ( I ) Tuh rriihuis illst asr.^ Where this has reswtwt treat- 
ment in a patient who shows no si-;n of il''wut\ tiil.eiriilos s, lar.laeeoUB 
.lis..ase. wh.-iv it is the onlv larjje joint alV.M t.'.l. an.l when- the powers 
of repair are .siillicient. If other treatiiu-nt fails t.. a sum.-l im! 
useful j<nnt, there is no gcnxl hising more time ; tin- miiHeles will only 
be more wasted, sinuses will onlv form m«»re extensively, an.l tl..- 
pati.-ni s h.'allh be more impaired. If caaeation has occurred and. 
still 111.)!.', if sinuses and mixed inf»<e ar.' pr.'seiit. it will be iinp.)ssil>le 
to remove the tlisease entirely bv 
excision; sulwenueiil ti.aihliso e 
ctirettings will Im; needi'd, and the rii k 
of a stifT joint is enonnoualy increase*!. 
The rule slioul.l be. especially in 
adults. fi>r .'x. isioii to antedate the 
above complicatioMs. 

{•2) Rictiil inj'irif <ni<l its results. 
\. Primary .•x. ision. When the joint 
is much opned. the cartilages much 
tlamage*!. when the shaft is intact and 

the tissues in front KOiind. an ex- 
cision inav Im- preferable to exjiectant 

treatnicnt. If asepti.' finin the iirst 

the operation excludes the of 

acute arthritis, and its certain sequela, 

a stiff joint. But here, as in excision 

for (liaeaae. the determination and 

pluck .if the patient will be im- 
portant factors. .Vn.l the a<,'e of the 

pati.'iit's tissues an.l .ir<rans will have 

much more weit,dit than the age given. 

in the decision between excision and 

amputation. , . . ^ . , ,- . 

B. Secondary excision. When acute arthritis, iM)t yiel.lmg to 

incision and drainage of the joint, has follow . d on an injury, an.l ankylosis 

» 8ee an intowsting paper by J. Wingate Todd. A«»aU oj Surgery. 19t3, vol. Ivii. 
p. 430. ,^ 

Tic. ''<■ 'I'll'- •i""'' illiiHtration 
hIh.w.s the i i.iil iimity of the .inter hi'ttd 
of the triii'lw with the fnsi ia ov. r the 
aneoneuH (.Mauwler). Too iini. li "f the 
poHterior aspect uf the ulna han Itmtk 


is thf lifHt reauh wki« h cnii t« iojmmI for uiUumt op«»fi<>n. li. lurh 
ruM'H, an th»> inflamml '-o. .lit ic;. i.i If Imtn's ami wtft |)iirt« iniiy |>ii«»wc 
infective rellulitijt uiic sd-oniN . liti > aftfi an <>|MTiili<m. it will In- « iscr, 
before exi'iHing, to ^ i ' till Jh<' intinmnmtioii lias sDiiH vvlmt mili-^ultil. 
It iniwt Im* lemenili nil tliu». in (*x«'i««ri aftfi mjiirw tcai-tioi. wilt 
proiwbly be gn»tet, .Mip(>iir uii.i itmre ••ertain. i»n«l u tviuU-wy to hmv 
snkylcMiH nwn nmrkc I, e«|M i iiliy if tlw' jH-riiwteiim m pnwerved. 
SuHit iiMit drainat!!' is nli iliitoly iirnifiil. 

(.») 0/(/ niinrn-'! Ill III' Ffhiii'r ,h nt. • niHiii'.- in stilTni'Sfi. iinkvl'wtH. «»r, 
niori' ran'K. |in'ssiirc <in tlic main \^sil hi ini \ c-t ninks ()|Mriiti\<' 
iiitiM ffrt'Mi !• ix jiwtitit'd in mn li <ii.s<'s, whi n- tli>' jialii-nt \x iitli<-i wise 
healthy and where hiw future will Ix- wiwarfy cripple*!. The Mktwing 
tn<Mle of treatment niuv Ih« i»tui»loywl. 

A. Fntrihfe Mimimttt »nder an AturdkHir. TWh, often remlting 
in the " infiiicti'-n " of soiiii' American sur|ieoiu. in not t« lie recnm- 
meiiiliHi. riif iisulfs art- rarely >jim><I. may Im> nil. and nmy l»e fnllnweti 
liv serious dania;i«'. Wliere the ne. .Iful Inrcihie inovineiit i« |minfnl 
uiui followed < onstantl\ liy swellin'; and \v> jiernianeni uu rease in the 
niolNiity «>f the joint, the patienf nnist (i t ide hetwi . ii a < ompleti' 
excision, performed on UImtuI lini«« and ha\i. ir the limli put u|i in a 
fixed position, at an angle an arut4> mm ]NiHHilile. 

B. Arlhrnliiiiiii. Openinn the joint, with diviMi<m of iMlh»«ion«. and 
attempteil reduetion of the disjihued Ixmes. will l«' found a step of 
very limited usefulness and is not to In; ri'eoiumended. 

(". i'oHipUiv Of juirtiiil f jti,iii)H. The |. inier i,s usually iniliiatetl in 
thtw cases. The quration of partial exciMnn for injury ia ^Kane^i 
at p. ir>!». 

The following is. very briefly given, an interesting case of exciakMi 
of the elbow for an old disiocatioB and fracture : 

M.E.\viiHi«»ntto Mr.Jaeuliw nin Fobniaiy IWM, l>y Or. K. l)avH>H. 
Sivanww. The injury, rpfeivt-d th«' jin'vi«»n» XovcinlxT while he wiih riilinK ovt r 
a »hee)»-f«nii in Tk-rra del Fik'K". hail never U-^-ri treateil. A ilinkKvitkm I'.irk 
ward«uf Utth bomnof the rijthi ell»i>w-joinl Wii^ ty|>i<'allv e\ iilent. ami. in adtlit k.h, 
then- WBH (listinet KlM)rtenin(! of tin- liinli. ( uIiIik'sh and livlilily "f llie liaml, 

ami ilHifient niilial pulse. The fnreanii «a- ti.xed ,il a m 'v oliliisc an(,'le. artivi- 
and pa.ssivi' innveinents lirinu alini«-t ( iim|>li lcly .ilioli-li' Dining the exi isiim 
it was fiiunil that a frartiirc ran . i v from uilli inwards thniuv'li tlie 
Iduvr third of tlic Innnenis. Win ii t lii' loiili wa- plan d 'he i xtnidrd |hisiIii.ii 
after the <i|M rati<ili. there wa- >lill a full one and i i|iiarli In s li. tween the Ihhw 
ends. Healing was inieveiitful. .\l the end of four riiiH tlie |i leul eiuild use 
the arm to play luwn lennis. shoot raliliils with a rille. am. !• . Five muuths ift«T 
the o|H'ratlon, extenxion ami protiiition were praetieally • . j-lete. tte\ion wtu- iuH 
enough to allow uf his touehme his right ear aiul buttottaii! km vtitltir-Htud »ith 
the right hand, hut not sufti< ientt\ |i«-rfect fur him to towb hiit rig^t tthouUrr. t?nly 
about half the mage vt au|iimtiun wan ptm*nt. In IW»r> iMtk-ttt wnwe. Haying : 
' * My right arm in aa uHcful t« mp ait it wa« befort- the ju-«-i<iiit . 1 t»n »*ieiir ahet- 
rkif. and iihoat with any niim." 

(4) Siimi' run' fiisi'y nf i>ij"ri/ In tin- Ijnirr K ■•; 'iisis • ' '-■<» Hmm-run. 
In the ijreat majority of tln'.se ju<liei<i treat? ', < -inM-ndly 
earlv examination .itid reduction ol the displacein umi an ' tie, 
and putting; up the elhow fully flexed with the liai >u tin ier 
will 8uth( e. Should thi.s not be successful, ai ix ti uperst? ih 
fixation of the .separated ej)iphy8i8 in good positf^t bv a «n» ^ rew 
may be e.vpecteil to yielil {jood ressits. There will h©we\ i'^ t-a dly. 

stiff, lit u (iwitwB iMigU> 111 '"^'^ ' '''""^ 

iiiira MrtH-ubr and mrt miwulttr. »ui.l l.r. ,.kii.« . ..I ^.-11. -iih is 
coiiMtuntlv f..ti.wrMl bv rwMrrw»t ii»Aiiin,,.tt..Mi. w.lhi.i,'. a...! I.v 

„„ ,,,,„•„, . i,„,,n.;...,onf. Tb.. =.»k>W Mwy to .««r..Ml 

,1,.,,;,„„ . Mni.,..-.l „i. I" r.oHt...., .., ,.. » ,».rtiMi ..I artiM-h«UlH|.l»yW'«. 
f|„. . p..-.., Ivl.-. h,,^ nt.' 1m ..-.l,..! l..-tW.4.|l til.' tr.rlil.-» 

.h.: sitMHUMl , itv. »liu. P-u.K MM). ui »f t ... |-miti.m itn- 

«,«„.il.l. I first. Intlirs. ■ x. i nuiv I 1m st > ^ 

.rf a Im-K IIH.V .1.1.- .iml u.s,.ful , .1. I-h L .v in .mk I. . • 

rar«'fiil tt\u\ tliurMURh rinl .t{ra|»»iH ••xuim .tion i. ! tli.- ■ j. 

i„ ,,„l,!il, ' tip .ir«.'.... • IIIMHI til.- U-M -Mir ..( tr.;.llll.:.l. 

Tl, ..lluNN,,..'!. ..rkHl. M K«-t» • on f h.' .Imiin.. ...f th.- .■..i..Hi..n. r 

inHin. s al... ^ >i <11«>n^ I" i" ^"''j' ' "•' • 

•• <on.|..n-. ..i " l\^o . ll.ov lli.- |.ali.-lit sl.uuM plan- til- tv - 

huiwln. .M. tl..- ■ niH.n tli- ..f tli- h-a.l 1 tl. n i„,n .1,.. 

.>lli.)W» a* war ••wh -.ili- r an |H»t«ilil.- in liont ..I 1 1,.; la. I i . i. ai.- 
,„,w t.w.» trianulM Ui I-' WHwpaml. Th.- Imw of . a. Ii f-.m..-.! oy !••»• 
uni' ■ • tli' fip« "f ! wo .N.iMlyli-H ; tlwapx wut th.- . !-« rai.<.ti m\ tl..' | will ni\W n IMlffilMtw IMwh-ii th.' .oii ...<1 

„i. „. • tl. n- Im a fia.tlir.- l..'tv\.-.'n t COIwlvl.-h 'li*- 

J. lit th-K- vvill •■ " of th.- .hstaiu-i' 1.. i svih-ii ' Ik- 

l, iiK-usiimJ bv . i-aii .1 .aliixTS. Kia.tnf ..f .itl, r,. . 

tlisturb the r. atioo of tl, .■xt.Tnal or int. inal .■..n.lyl ■ 

two f»intn. If th<- hoa.l < '\k radiiw is .lislocatcl ..ut\ ' • 

wanls its liiiul ull Imhohi. ort- pr(>niiiu'nt tliaii on th.- . 

A supr ...K'vlar Iractun'oi ■ jmration of th<' pp'pKvs"* ' 

fr,„n I ; ,. ,„.ii! ' ..f su. Ilin;; aii.l til.- piiin in r.= ili<- i" 

, il,.,u h.' .'II. -lioiil"! ii'^^t I"' " ' ' 

h1 VI ..l froi.i h.-liii,<l. A ia<li.>).'raplii.' . - mir i ^houUi - 
v.„ubl\ i.. ma.l. from till' Hi.i.-airl in f! .1 ' w.s sl...iil.| 

In- .'xanii' ' ' , 1 , r ■ 4 

(.-,1 /„.s/ a fuuKirposUiim. Th.- foUowi. ■ tli. , hi. f i...iiits 

^vhi. h ui tli.-ins.-lv(»s for«lpratkm : II w far th.- an«l«' 

is an ohtu- aii.l tlf po.sili.m of th.- liml. su. h as f.. i.-ii.|.t it uw- 

U-HH- th.- a.. ,.l vitulitv <.f th.- pati.-iit. an.l his u.t.-r.-Ht ni poss.-ss.nj.' 
a mobile joinl . fh.^ c.n.lition of th.' inus- l.-s <f.H > th.- ^ 1..- ol 
Ions staudinK these nmy b.- ho utt.'ilv atr., in. '>at th- .is.'fhln.'s.s 
of the limb will be but little incn as.-.l l.y op a- th.- . ...-xist. !.. 

.,f any .icatriciul ImmlH, especially in front, «ill nit.-rf.i- with 

th.- aft.-r-i.'siilt 

A bilat.'ii.i ankvL.sis. .-sp.'.iallv at ..n-.-j.-s an.l in vounj? 
subieetM, oalls UI•^^.•ntlv for ivs.-lion. th- op.'n.t.nns 1,. u>u' p.-rfornied 
at an interval of about f..ur w.-.'ks. an.l fh.- liml. -i ■ i- 'h" >"'is. l.-s 
are least wasted being taken Hrst, so that a p.o.l r.'sult ii.a'. . ih ..ura};.- 
the patient. The m«>re eomplete the ankyhwis the more th* tuiilar 
stirfac. s ar.- fix. il tlir<.utrh..iit {i.e. iu4 at ihu- spot only. e.g. .rf--ranon 
tip t.. ..l.-( rai...ii fossa), tl,.' (.'r.-ater tl«- thi- k.-ninir of the pero«t«um, 
the more an- no.lul.-s or .spi- - f' '"^ rait-i-.l about in the 
ligaments, th.- moir H.-.-ly must th- i.on- - ..v-.l l-iirth.-r. in all 

cascB of bonv, the 8urg»- sho,., \„„u .i • ii- -a-- ••: 
the superior "radio-ulnar joint or a« ankylosi.s h.-re may 1. .>\-rlooked 

' Cliit.J"«rn.. r.l>. 4, 1903. \i. 247. 


after the main disease has been treated. Mention nviy be nutde of the 
method of r^mium ecmwmique wliich the infieniiity of French surfreons 
has led them to try in cases of ankylosis after injur}'. Here, after a 
removal of the bones leas free than that which is advise 1 below, a Hap 
of niu.scle the triee|).s is brou<;lit between the resected ends and 
attached to the cai)xnle in front, to prevent freah ankyh)sia ocnirring.' 
Perusal of some of tlie recorded cases conveys the inii>ressioii that 
the result, especially in children, is not superior to that of tiie older 
method of a free resection. 

(()) Diumtjatmiwj arthritis oj vlhur after one of the exanthemata, 
pyaemia, or rheumatic fever. 

(7) Ostco-arihritis. If the patient is healthy, not advanced in years 
(/.*>. not much over forty) and not l)roken down, if the muscles are likely 
to riTover their tone, anil if this is the oidv joint attacked. The sur<;eon 
must be prei)ared for sawinfi very bones here. Dr. K. W. ('oliinson 
reports a instructive case of excision of both elbow-joints for 
osteo-arthritis.- The patient, a-t. 22, was admitted into the I'reston 
Royal Infirmary. June »>. 1H90. 

The disi'iisi' lia<l Im )!iiii wIkh she was cl. vi-ii. .Ml IIh' jciiiits u. iv mure or K-s.x 
alTrc lccl. Till- ritilil clliow was alisiiliitcly lixcd. When a1t<'iii|its were iiia<l<! to 
move it iiiiiU 1 all ana slli< lii the hiimeniH gave Way at it*» lowi r epiphynial junction. 
'I'hi' left . lliow joint could only U> tiexwl thnmgh an angk" from 8 t« 10 degntn. 
'I'lir right joint was excim>d Sep»emb«T ft. iJie left in I^M-ember I89». Both healed 
(iiiicklv. Ill -Viigust ISOl thtw was on the right side alniont jicrfect. flexion and 
exteiiHioii with nmetieallv iio lateral movement. I'ronatlon and siipiiiatioii were 
absent owing to the ahwifute ankylosis of the wrist and inferior radio-iiliiar joints. 
On tlw left Bide extension was not <|iiife so };o<«l. a eiMtain ainonnt of lateral move- 
ment i»misting. Uolh hands were now most useful. .\s an instance of liow 
crinplpd the jiatient l« en Ix fore the o|K-ratioiis, when eating she was coin|H-lled 
to plaw her plate on her knees, she 1 hen lowi re*! Iht head and raise*! her kneeH. and 
thus managed to get her fiHid into her mouth. 

The foUowin^ points call for consideration in any case where exc ision 
of the elbow is beiii}? discusseil : 

(1) Age. This must always have much influence. In very young 
children <lue attention be paid to the naturally great power of 
repair. .Vfter thirty-tive or forty the sinv'eon should weifjh very care- 
fully ail the points of the case, and only excise where all else is favinir- 
able. Frtmi puberty to thirty-five miy be reo.iided as the best ajie. 
Those who see much of the sur>;ery of childhood will, of course, be 
called upon to <lecide up<m the iiperative treatment of tubercidous 
disease of the elbow-joint at a much earlier date. During the first 
three or four years of life resection is certainly not to be recommended. 
This is partlv due to th(> fact that, owinji to the greater t<>ndency 
to repair, less severe steps r.ij. ciirettini;. removal of tuberculous 
foci of osteitis and caries will ofti'ii be snilicieiit. but partly because 
the surgeon will be driven to hold his hand on account of the feeble, 
miserable condition of thoho patients with tuberculous di.seuse of a 
large joint so early in life. Owing to the diiticulties. inevitable during 
tin* after-treatment, in carrying out active and passive movements, 
the surgeon must be careful to keep the limb, from the first, at a u.seful, 

an acute, angle. After the age of four the patients, owing to their 
increasing vitality and resisting power, are better fitted for resection, 

• QiiinM. HhH. Mfm. rfr la »N-. it ('kit., Jttbl 27. I9(», p. m. 
3 Lanrft >»*•)). Nov. 4. p. 12^ 


hut the activity "f tlio |H>iiost. iim. toji^thor with tho fact that it in 
i,n|)o8Ml,U- to r.-lv U1...I. tlu' patients for any hWp in active mobihsation 
of the joint calls for free removal of i)ou«'. 

(2) Comnlimtmis. These aiv most likely to present theinselv.'s in 
the shape of .Hsease (.f other hones and joints, for such a conipiuatiou 
as phthisis will probably call for amputation. I'anes of tlie ineU- 
• arpal or metatarsal bones is not of itself a contra-mdication. II a 
.lisease.1 spine is present. tli<' .piestioii of excision will depend on whether 
the vertebral caries is old. or rec'nt. or active. If old, is the elbow a 
source of much irritation * Two lar<;e. 
joints are rarely diseased at thv same 
time. Mr. Holnies* has recorded a case 
of a l)ov. a^'e.l .">, when he excised, with 
excellent results, both elbow-joints only 
a few weeks iiiterveniiifr between the two 
operations. Mr. Clement Lucas - n lates 
a case in which disease of the left elbow 
came on about two years after excision 
()f the right joint, iiml was also success 
fullv operated <m. Since ISKti Mr. Jacob 
son has exci.sed the elbow-joint with jjood 
results in four children, in whom some 
years before lu- had successfully i-xcised 
a knee-joint. And in one of the four he 
had, later on, to remove a tuberculous 
tarsus bv a Symes amputation. When 
this child was seen a year later all three 
operations were sound. The new elbow- 
joint was a very u.seful one. 

(:j) Qiwuliun of the Vuliw of Preserv- 
ing the Periodeutn. While the perios- 
teum may be easily preserved in cases 
where it "is swollen and lo«we, its preser- 
vation is in others a matter of very great , 
dilhculty. rendering' th(> operati.m much j '';,( ' 

more laborious and prolonj!ed. and it is ■ ■•■ 
e.xtremelv doubtful if it is of anv ad 
vantage in this joint, where the ordinary 
operation gives such excellent results. ' 

Some cases f.f/. primary excision for 
injuiv are unsuited to this methml. as 
the unaltered perio.srenni is nu>8t difficult 
to remove from the irregular bone ends. 
In tuberculous disease it is often un- 
desirable on account of the risk of leaving 

mischief behind. . . , i i i Ko 

Subperiosteal resecticm is said to lead to less ha inorrhage, less .lis- 
turbance of the capsule and attachments of nmscles, with greater lateral 
steadiness and completeness of the new joint. While the last two are 

' Clin. S,>r. Tnian., vol. i, p. 14:1. 

* In Um oMe of excWon of the •huukfcr-jomt (p. 222) the cundiUons tire very 

1- .. 7t>. IllKllt cllttPW ilftl T cs 

liwidli of 111'' joint l>y till' iisiiul 
jMistriior iiicisiuii. ( K.iralK iif. ) I 

ils;i > of llir iiuirr r.\- 

tin' tricopa tcnilon. 
L'. I'Ina. •t, Hiimi-roit. fl, An- 
i iiiieiis. I'ovcn-il hy »l. _ t)iit< r 
i'\|miii<i<>n "f tnrr|is. 7. Sii|ii- 
nator lontfiis ami nidial i \lrii<i>rs 
lit the cariMis. 'In tin- litflit the 
Imiies ii inovril iliirili« the i)|K ia 
ticiii are si i ii. Tlie Imnienis lias 
lii i'ii saw n tliiiiii«li at » ixiintMrtiiP- 
H'liat lii^lii r tliaii usual. It will 
hImi Ik^ uiitii'.-il that care h«it been 
taken not to uiululy i'.\poi» the 
Bliaft u( tho ulna. 


un<loiil)tpd. this step may l)rin^ about impairefl mnvomont.* and the 
sur<;<'<)n sliotiM only tioiiMc to iiri'scrvc tlic iifiiostcmn. wliili' clciiiiiij; 
tli<> lowrr t'liil (if till' liiiini'iiis III its iiii|Mii'tiUit inusciihir iittiicliini'iits. 
t'spi'riallv in casi's wIhtc an unusually laijtc amount of lioni> has to 
Ih' removed. If tin' pciiostcum is kept, the removal of the l)one will 
Im> adiiitionully needed. 

OpmtioB. The single vertical iiHixion at the back giveK Hurh 
excellent results that this operation will alone be fnlly described ; the 
iiu'thod by two lateral and a sin}.'le bayonet-shaped incisions which 
have the jirefereiice by h; di authorities will be jiiven later. As in all 
ditlicult and luit very coninion operations, the sur};eon will act most 
wi.sely by practising: one operation. An Ksniarchs bandajie havin<; 
been ap]ilied as hi^di as possible over the upj)er aim. which is first well 
elevated, or the whole liuib being rendered evascular as far as the above 

point by the use of two 
l)anila};es. the limb is fie.xed 
and carried over the front of 
the trunk, so as to |irrsi'nt it 
fairly to the surgeon, who 
usually stands on the opponte 
siile of the body. 

The stirgeon. then, ncrting 
the relative position of the 
condyles and the course of the 
ulnar nerve, makes a straight 
incision of scfHcient length 
(about four inc 'ii in the adult) 
with its centre at the tip of 
the olecranon, a little internal 
to the centre of the back of 
the joint, and parallel with the 
ulnar iiervc. This incision 
should begin above or below 
as is most convenient, and go down to the bone throughout its whole 
extent, splitting the triceps, muscle and tendon and incising the 
capside. Partly with the jMiint of the knife ])artly with a ruginc or 
elevator- (Fig. the surgeon then raises, as far as jiossible in one 
piece and without tearing; or jafrging. the outer half of the trice|)s. which, 
with its e.\|iansion into the deep fa.scia of tlie forearm over the anconeus 
(Figs. "."» and 7<) ) this latter muscle being drawn uj) at the same 
time is j)eeled up us thickly as possibly from its iiusertion into the 
ulna. It is on the preservation of this expansion that the regaining 
of active extension will depend. Resection-knives and elevators of the 
French patt^ern (Fig. W») are the best. 

' A <i;«' ii ([ivrn (l.(iiiij< nliirt. .trrh., vnl. viii. p. I.'tli) in wliicli. aftrr .«iili|K'riiiNti'iil 
n srction. tlir ciinilylrs liad Imh'II vcn pcrfcctlv rciiroiliirrd. aiul tlir iili'criinini liad hvvi\ 
ri'fnriiicil til even an inrniivi'iiiint i'.\trnt. fur it was sii Untji anil curved ax siimcwhat 
to iimit extpniiion. ThiH mcthml t.h(HiM usually lie rejertcd in rhildrpn. and also in cwcR 
of nnkyloHis. for fear of a rwiirn-nrc. The eandtil Prof. Oilier, with all lii« ex|KTienco 
wiiite (fur. MH/irn ril.. p. 2IH). •• Aiissi. npn'K iiiie rewetiim wins periostee. est-ee la roidour 
ipii est plus a i raiiidre ipie la trop (.'ramie laxite." 

- l*!i!i'?<s the tissues ;ire stifteiied !>y iiiflaminatiiiu ativ lilimt dis)a'c*nr« " nrr ii«rlr^-. 
Any |H'riusteiil elevator, i .ij. Ilie one shown ill I'if!. SU. should have a diHtinet liut not 
Hharp (Higo. If the knife Ik' iiHeil eaeh cut hIiuuKI bu nhurt, and, as it ii« made, the edge 
m«i>t vvw b« kept tniMd towwdi the bone. 

Flii. 7". 'I'll xhdw the level to which tin- 
bonex are to he eleanil, and tht- way in 
which the thumh-ntil ih kept lietwivn' the 
knife ami the mift ]iartii. 

KXf ISiON OF THE «i#OW »«1 

Tl... ,l..,.p.M-i..rts ..n tl..- uufvi si,l- of tlu- joint iiri- th.-n s.'parated 
from tho bom-s with tlu- >'M<,v until th- .■.m.-IvI.- an-l tl.o 
head of the radiuB are cinpl.-t.-lv . xpos.'.!. I h.- IHt thun.l. all l.o 
Himk into the wound, pushes the llap of soft j.u.1. . as it is ,l.-ta<ii.-.l 
towanls and ..ver the external condyle. It is. hna ly. displao d ov.-r 
this as th.- joint is il. xe,! stion^dy. Next, the part*. .m the HMjer side shouUl 
l„. detached from the inner c..ndvie and inner JmrrJer of th«» alecrai»«fi, 
Hreat care heinfi taken, l.y the following piv.aut.ons. «<' keep int«rt 
the uhiar nerve: (o) By keepin- the knife or l''''-;"''' 
nerve and dose to the hone ; here and on the outer side alike the inst 1- 
ment should follow ch«ely the .litlVn-nt Ih.i.v irnrular.ties aioun- the 
ioiiit ih) By the use of the thun.l. which displaces tV sj.ft ,mrts as 
ihev' are separated l.v the knife. By these nH«n» the «rft p»rts »^ 
be "satisfactorilv cleared from the Imiiu'S ; retractors well appbe«l wm 
be found most useful, as the process of peeling otT th." s<.ft parts W soinr- 
what fati^uiuK to the thumb. This is esp.-cially the case in exeisi..., 
for aceideflts or on the .lead IkkK-. an.l it is in these onlv that th.- nerve 
niav be seen, though indistinctly. Wh.'ie the parts have been lonj; 
inflamed, they ro-el off much more readily, and the nerve is bnne.l in 
the swellinn.' it is well t.. remember that the nerve niay be injure,! 
at three places : (1) Above, in the inner head of the tnccps; (i) be- 
hind the internal condyle; (3) below, under the extenaor carpi 

"'"ihe clearing of the soft parts otT the bony prominences will be much 
facilitated by keeping the joint extended as much us possible, ami the 

''"Vach^!ter'ar£ment. if this has not been already done, is raised, 
toeether with the periosteum and the group of flexors or extenaors 
respectively freed from their bony attachments and pushed oyer them, 
and there "retained with retractors. The joint is now str-onply flexed, 
and the capsule opened just above the olecranon. I he bone ends anr 
then turned out and prepared for the saw by j.assmg the knife down tj. 
the bone ii. the lines of intended section, the soft parts being well 
retracte. ■ ^ o, d these lines. In turning out the b«)ne ends it is easy, 
in patiei < v. i -re the parts are delicate or softened by inflMimation. 
to strip o.: < needless amount of pffliosteum, e.g. on the anterior aspect 
of the shaft of the humerus. , , . , , i 

Kte ol kone section.- The ulna should be sawn (from behind forwards 
with a small Butcher's saw set firmly), so as to remove the greater and 
lesser sigmoid cavities with the olecranon. The radius is removed at 
the same time just below its head, above the biceps Before this W 
done the assistant, who is holding the forearm, should thrust the ends of 
the bones prominently but carefully .s''/>m) int.. the^wound. 1 he 
section of the humerus re.juires careful attention. An msufhc-ieiit aniount 
is usually removal hero, and limitation of subscpient movement thereby 
invited. It is generally considered sufficient to remove all the articular 
cartilage, the section being made to pass through the low-er part of the 
coronoid and ol(>cranon f<.ss«>, an.l beh.w the level of the ejpttrochlea 
on the inner, and thn.ugh the epic.n.lyle on the outer side. This is not 

• K..r the Hak.. .>f ,,m< ti. o. it i- wvll to t»k.- th.. ....tir si.lf tiiM. before clearing the inner 

with the uhiar m rv.- in pn.xiniity to it. 

* Refer aliio un thi> point to Fig. 7U. 


enough.' The saw shoiilil pawt ut a lii^hcr IovpI. i.e. above the level 
of the ejik'oiulvh'. and thi()u<;h the liiirlicst part of the ciHtnifhlca, 
removiiif; ((iiite the lower two-thirds of this process. This is tlie very 
lowest level at which the s;iij.'eoii sliould hold his liiiiid if he desires to 
obtain*good inoveuient.- And before he is satisfied (;n this )ioint lie 

should place tl.e fiii<;eis of the 
atlected limb not only on the 
(ipi)osite sii<nihier and the month 
(as is often done), but on the 
shoulder of the same side, and 
behind the back to the angle of 
the opposite scapula. 

I'nless these inovcineiits are 
perfectly free, lie should take 
another thin slice off the humerus, 
reinovinj; the whole of the epi- 
trochlea. 'J'liis stcj) niav .seein a 
Fig. -H T., ^ho» th....iMni.-..ti,,„.,f.l,,. shortening of the limb, 

mw. 1 he dottfdlmc! acroKS IIh' limiit riis i i i i ■ i ii i ■ 

pMMti abovH the articular rartiliiKf. but and likely to li-ad to a tlail-joint. 
is not Mgh enough (nVc iM/ra). Such, how ever, is not the ease. 

As long as the elbow-joint is 
freely movable, shortening of the boiu>s matters very little. If atten- 
tion has been paid to the advice >.'iven at p. I-")|. and the soft parts 
separated very carefully and. as far as |iossible. subpcriostcall\- lioin 
the epicondyle and the epitroehlea. the joint will become suMiciently 
steady laterally as well as freely movable althoii<ih these bony prominences 
l»ve been widely remo%ed. Another test which the surgeon should 
always apply before considering the section of the bones completed is 
the interval between the sawn ends. 

Professor Annandale considers that an incJi anil a half should inter- 
vei.e between them when the bones are exteaded. This will be noiu> 
too much in adults, especially in eases where, owin;; to the condition 
of the parts, recurrent inflammation is certain. Here two or even 
two and a half inches separation is desirable.' In all cases (and this is 
especially so in those of ankylosis' where a recurrence of the trouble 
is to be dreaded) more bone must be removed from the humertis than 

' If only half uii inch iif huiiicruH l>c ri'iiuiveil. tciycthcr «ilh thi- lnjid ef (he iiulius 
and the olecnuiun iMrocew) — the latter jierhaiM <il>lii|iu'l\ -iinliylii>i,-i i.s i rrtHiii. 

» M. Oilier {Tmile den RfwftinHx. t. ii. p. 2U:t| iiMiully iiml«-s tin- f-c>i ti.iii at a miich 
hiflber point tbnn Iiici>l kitj/ohis. He lirst !-tatr> that tlicM r'ioii nf th<- huim riis may lie 
made at (ttllemit levels: fl) Thai which n-nio\c,-> tin' artimlai Mcfuf ojily. tin miIi- 
ppitroohli'ar ; (2) That which pasnrs just aliovc tlirouv'h the «ul'.->taiuc cit the c|>itrin hica. 
the iiitratrochliMir ; (S) Thiit which i>a.-,-i's just iilmvo the vpilnH-hlca. the nupra- 
opitriH'hlear ; (4) That |»kmiik thniUKli tlic ishuft. Hu tlu'ii «i>f(i on to Hay : •• The m-etion 
imiet frequently made— that wbirh v» indicateti iu the nwjurity of cuk-h of chronic joint- 
dimute, whether in young or oM Hubjects — is the hccUoii above the epitroehlea," i.f. 
number (!(). 

* Mr. Whitchcrtil (Urit. MkI. JmirH., IS72. vdI. ii, p. 554) riM.nls the case <i| un 
ailiilt in which two «nd a half inches nf the nhaft td the hunicriLs Imil tn Im' leiiKivcd after 
HiiwiiiH off the condyles. The prttient was the Kuhjcct of tertiary syphilis, and the o|HTa- 
tion wa» performeti three yeant after an injury to tlie elU>w. 'I'hi' joint is stated to 
have been completely dinorKaniRed. Sine luontba ^ho wait alile to follow hci- nei iiiiation 
aa charwoman with full ui« of the joint. 

♦ In caaea of bony ankylodiii. it in well, liefon' attempting (o niaki- si-ciii Tis of (he 
bonea, either to break down the union forcilily (care bein); taken not to frai tnre t hi' | 
atK^hied biMw abuvo and beluw, or to iicparatc any of the epiphy>i"s) ; or, better, to 
^vMe the aolnrMa, witk a MW, chM, or oateotoBt*. 

from those of the {(.rearm, where the section is Umite.l In the attach- 
ment of important, miUK.le«. The extent .,{ b,.ne to l.e rnnoved ha hr 
been detailed, it is weU to renn n.her the adviee of I'rolesso K<h h. r 
to «.ake the sawn section curved. It is especially in.portant to do so 
with the olecranon, as this step r.k^s a lon^ way towards P«^»-ntii^ 
partial .li.loeation of the f..rearn. forwards and also p.ves g«K^d leverage 
for the triceps. Mr. Holmes has pointed ont. lonn ajio. that if. alter 
^mlvin^as "Uich l, as is disease is still felt upon 
surface, U is not necessary to make further se< t ions so as I' ' P^J^^^ 
it ; thorough curetting will be suflicieiit, and wiJl save any further inter- 
ference with the attachment of muscles. 

Chevne and Burghard '^ give the following at. vice here, winch is on. 
reconiinendation of the method of two lateral mcisions : 1 he hnger 
can be made to pass from one incision to the other between the capsule 
and the superficial structures, amongst which will be the brachial 

*^"*^y passing the finger across from one incision to the other and 
shifting the soft parts upwards and downwards, the entire front part 
of the capsule can be separated, and may Ix' cut across at its attach- 
„,ents to'the bones andVemoved whole." While the boj^. ^'fj**!'' 
the olecranon and trochlea of the humerus may be steadied m the gnp 
of a lion-forceps, the s<.ft parts being well retracted/' Any soft, caseous 
patches in the bone ends are now gauged, any possible se.|uestra removed, 
fn bad cases the bones are Hable to be fatty, with little natural ma. rovv , 
such, however, are not necessarily irrecoverable. If the bone above the 
levels of section appear roughened, and the site of periostitis this need 
not be touched; all will probably sub.side when the cause of irritation 
is removed. Anv sinuses or suppurating pockets should next be Wia 
open, with due regard to the ulnar nerve, and their content* scraj^d 
out with sharp spoons. The extensive wound should then be thor.mghly 
irriKated with sterilised saline sohiticm (temp. lUO hahr.). A 
drainage tube should always be inserted, as consuU.'rab e oozmg is 
certain to take place. If infected pockets or sinuses have been opened 
and scraped a few sutures may be used and additional drainage secured 
bv packiiig these with sterilise.1 gauze soaked in iodoform emulsion. 
Very varied forms of splint have been a.lvised.« Some surgeons, to 
keep the bones apart, from the first put the limb upon some f..rm of 
right-angled splint ; others, fearing a flail-like cnditi..;. of the joint, 
prefer to begin with the arm and forearm oa a straight splint, or ..n 
one with an obtuse angle (about 135 degrees) some form ^"'f^^'] 
angular splint, allowing the degree of flexion of the elbow to be altered 
at each dressing, sli.mld be used. Cases may be put up from the 
first on a metwl angular splint, using some such cheap form as that 

• Trxt book ofOiH ralitH: SHrgery, Stil.Vs translation, third ^:n^ K.lition. \,. :M7. 

* Mnnnnl nfSurqical Tnnlmenl, in. \y'2iH. ■ „ , ,.i i„,i,.,r 

3 Mr Heath thinks (/.,r. ..«/.r« rll., tliat " tU>- uhiar »i<rvo i» in more dangi-r of In-mj! 
cut wi*htho "iw w^n th.. ulna's .livi.U.l than when the «cti«i ol the h««en« b made, 
it iH-inKmon'iUmoult to dearth.- former Umo." , j . 

4 F^^ralHuf (.!/..«. r.. I-. 710) IK.ints ont that .f, to 

of the ellmw, the, wrist, or linn. rs are stiH, ..|MK.rtunity «houM now be taken 

«tr«t~ «,.nnt U hen, Uis,K,n.... wi.h The .... of "- » ''i; V^^'j^f 
whlJn> rHPrriL b«4e end. h.« h-nknown to pfojeot fn>m 



ilfscribed in tlu> liril. Mul Joiirii.. IK77, vi.l. i. p. 774. in which the 
antoridr nii-tal Imr supiiarts tlx- liinl>. wliih' it h-avcs the w»iun(J and 
its vicinitv well expowd and is easily kept clean, both parts Iwinp 
readily boiled in a steriliwr ; moreover, the movable handpie< e n addy 
admits of wm\e early passive pronation and supination. The only 

Fic. 79. Ksnmn h'i. wm- Hplint for rxcisidii nf li-ft cIImiw. Thi- siipinc |iositinn 
iif thf liatul. wliirh it is ini|iciiiaiil to |ir. m tvc. is wi-ll niaiiitaini'd in this splint. 
I'la^tt-r of Paris ban<laKt-s nmy U- u.sfd. 'I'lii' Mpliiil sh-mld U- liciit to an atiite 
angh-. (MacCornuK!.) 

objection to this splint is that it does not f;ive ((tiite enough support 
to the limb. Volkiiiaiin s (based on that of N'athan Smith for the 
lower extremity). Ksiiiai( h"s (Fifi. 7!t). and ( Mlier s. all of wire and 
easilv bent, are better in this respect, and all admit of the lind) 
being slung- a great relief to many patients during the first week or 
so, this position also readily showing whether any discharge has made 
its wav through the dressing. Plaster of Paris bandages should not 
be employed to fl.x the splint owing to their cramping effect upon the 

Passive movement of tlie fingers and wrist should be begun on the 
second or third day. The joint itself slioidd be moved as soon (but 
very gently and slightly) as all irritation has subsided -about seventh 


Fio. 80. A, Fsmlwitt'a mgim. B. Oitter't periMte*! efevstor. 

to tenth dav - this date varying according to the size of the gap left 
between the sawn bones, flu- jjrobable condition of the tissues as to 
inflammatory exudation. &c. In children an anseathetic may have 
to be given several times. The angle of the spUnt should be altered or 
the limb put up straight for a few days, and then again flexed. Later 
on weight-eztoiKcm abouM be used, by secBring a bag of sbol, whicb 


u aMed to from dav to .lav. A iH'tt.T .iu>th<.(l. .-sptM iaily with childr.M.. 
lunaimp it is gradual and gentle, and one that can be luado interesting 
to them is the oM-faHhioned one of weight and pulley. The patient 
is with tlie ellu.w n-stiii}.' iieiir the edge of a table. To a pulley 
oveil.ea.l a n.p,. .airvin;: a w. i-ht is attached. The patient graap* 
til,, free riid of til.- iop,> with the hand on tlie sound side, while with 
the other he h< the a little the w.-i>!ht. The rope 18 now 
nulled upon with the hand on the sound side ; this tle.xes the joint, and 
when the pull is relaxed the limb is extcnde«l. This should be praetLsed 
assidiiouslv until half an hour a time two or three times a day is attained. 
To 1... of use this method be begun early. The elb<>w must be 
kept firmlv on the taMe. or the movements will Iw made at the slioakler- 
ioiiit Later, the ^olln<l limb mav be fa.stened up. so that the child must 
use the e.xei.sed joint. But when these aids have t.. be resorted to. the 
result will often imperf'x-t. The surgeon should put himself on the 
safe side bv ensuring. origii>ally. a sutticieiit gap b.-tween the bone ends 
when he lises the saw. The best test of the future of the 
litni) is that the tirst pa.ssive inoxements are free and almost painless. 
Thf .rottiiK' of children to use the joint is often miwt difficult, as fnends 
are usuallv too foolish lo .se.- tlmt the surgeon's directums are earned 
out dailv, because thev a little brief, but most neces.sary. .suffering. 
Parents' are far too ready to think that because an operation has been 
performed, and the woiird nearly, if not .luite, healed, no more is 
neee88ar%-.' In commencing pronation and supination earlv the uliut 
should lie steadied while tlu- hand and radius are very carefullv moved. 
The liivst attemi)ts at passive movement should be exceedingly gentle, 
and too much .should not he attempte.l at first. When the parts are 
sufficiently Hrm. usually at the end of two weeks, the splint may be 
left off and a sling sub.stituted. 

Falls must be carefullv avoided, and no liberties taken with the new 
union i.e. bv a patient attempting to do too much with the limb, as 
in liftin-'. Later on. when an increasing range of movemente may be 
allowed" resort to a r;vmna.sium will be very l)e!ieficial.' Finally, it 
is always to he ivmcmberv-l that a twelvemonth i. 4 elapse before 
the full benefits of the operation viz. a complete c<mil)inati(m of mobility 
and stabilitv are gained.'' o i ■ • ♦ 

If at the end of four weeks, movement is so free that a tlail-joint 
seems likelv. the limb should be again immobilised for another mont^h. 
.•ithor on the splint or bv i)laster of Paris bandages. Should flail-hke 
union still threaten the pati-Mit shouM wear moulded leather supports 
for the arm and the forearm, the two portions being connected bv two 
jointed metal bars which permit of llexion and extension at the elbow, 
but prevent all lateral mobility. ^- 

Tests o! ineewn. In about four months from the operation the 
patient should be able to move the new joint freely and efficiently, to 
dress and feed himself easily, and to lift fairly heavy weights. But it 

I Pronation ami Hiipiimti.m in a <tiil.l ^n■„ n.ily np|..inMit. tlir forrarm aii.l arm 
beinirrotaU^l tiiitcthiT from till- slioiililrr. • i i.i„ , „ 

whw« »n injury to th.. . ILow-joiot nMp.irmj: . x.ision .-M.x.sts «it , » 

humonw ncci-s^itutin- iihsnlutr r. st .,f tlir liiiil.. H' lv iho <"'i- m"^* removed 

vi-ry f^'y- j,^ .,, „.i„^,„„ .i.„j,, ( 4„„. Surg.. 1013. vol. IvU. p. 430) on " The 

End Reratts id Bxciirion o( the Btbow for Xubetoukwia.' 


will bo nine months or a your before the joint is thoroughly iirni iiiid 

S«96ftt«d ueirioil. Mr. Jacobson has tried this in three eases, two of 
them instancn of obstinate tubert ulous disease ; in each a very useful, 
bwi murh shortened, limb resulted. In the third, partial excision had been 
performed at a provincial hospital for an injury to the lower ei)iphysi8 
of the humerus in a boy of fourteen, lireat pains hail Ixen taken, 
but the lind> was almost completely stiff and at an obtuse alible. After 
re-e.\cising the joint completely, a useful angle was .secured admitting of 
the hand being brought to the mouth, placed behind the back, &c., 
BO that the boy could feed and dress himself. The movements of the 
joint nltimateiy remained much reatricted owing to the absolute apathy 
and indifference of the patient. While opening up the old wound and 
again separating the bcme ends gives excellent access to the remaining 
disease, this step will be but seldom reijuired if the rule is followed, 
after excision of such joints, to give ether rejieatedly as 8i>on as there 
is evidence of persistent disease, and slit up any sinuses or undermined 
tissues, thoroughly use sharp spoons, and. if needful, pack in, for a 
few hours, strips of iodoform game wrung out of an emulsion of glycerine 
and iodoform or sulphur, (i!^ the remarks made on this subject under 
" Excision of the Wrist and Knee.") Where, in cases of faih-d excision, 
the tuberculous mischief has burrowed out amongst the nujscles, where 
osteitis and o.steo-myelitis are also present, amputation is to bt ]»re- 
ferred. especially if the general condition of the patient is not .satisfactory. 

Other methods. Kxcision by a single ptwterior incision has been 
described in detail because this method ^v«» the best results 
in the largest number of cases, and is best suited to the majority of 
operators who will not perform this operation very frecpiently, and 
who should, therefore, strive to perfect themselves in one niethod. The 
above method is very simple ; it affords, if freely made and efficiently 
aided by retractors, ample exposure of the joint ; it« limited interfertmce 
with tlie triceps does not prevent the regain of complete extension. 
Therefore other methods will be very briefly given. 

M. Oilier, while admitUng that the single pcwterior incision allows 
of the fulfilment of the es.sential conditions of the subperiosteal method, 
considered it inferior to his method he< it affords less facility for 
the different .steps of the operation, gives less room, and is. besiiU-s, 
inferior as regards the after-treatment. A final and especial objection 
given is that this incision cannot serve as an exploratory one when the 
surgeon is uncertain whether he will perform a complete or partial 
resection. These objections are, however, not serious one.*, and, with 
regard to the last, paitial exdrions are not to be reconmiended. 

OlUer'i Method by a Bayonst-ihspad IneWon. TIhh imtlKHl. tlionKli p iu lally 
pn-frm-d by the well-known Lyonn Hurgofin. wits iiitrixliict'il liy liiiii is|)<Tiiilly 
forca w's ill whit'li ankylosis, which wulil not U- hrokcinlown. wus incsi n( in an 
('Xtciidc'l |H>.sitiim. An im-iHion, vertical at tirst, made above, ovit thi- cxlcinal 
siipra oomlyloid ridge, Hinking between the triceiw and sii|>iiialor lungiis fnim a |M)iiit 
two and a half ineheH alxive the level of the joint to tlu' top of tin- exit rnal cDiKlyh-, 
and pa-si iig verllca!!y down over thin : the inei»i"n then pa.ssi's <ilili(|iiely a. ii)s.s 
the oleeranon k'tween the outer head of the trieeiwandaneoiieus, and below deseemls, 
vertieally again, upon the ixMtorior bonier of the ulna for two ineheH. Through 
this, the main incision, the external condyle, head of radius, and olecranon are dealt 
with. To expow the inner ooodyie, make suie oi the uloar nerve, and to detach the 



w,ft mrt« »ml Intrral ligament, a «K>ond Hinall innmon. about two '«Nf^ 
mU iufmal to thr ulnar nerve an.J ,Mirall.l with tlu- nin.r U.r.l.r »f >' ' l-""^ 
Tte inciHion iH at .irnt a Huperttcial on.-. Ah it in ;"Vf«'"y,''" irr::'; 
mcntiom-l intornui-oular ,.lan..« an> ickntiti..!. an.l along th.-n.. I'"''"'^ ^^J,^ 
ami ioint an- nach.Kl. I.y division ot the ixriOKt-nm an.l <a|>Hul.'. The opmUon 
uJmlZ on .h..-|i,u.H aln; giv-en The Wl-ingarj, ^J.-oUo™. to tke 
nl«.v.- nu tho<l III th.- liwt ulaw. ankyloHis in the extonded poHitum w a iwre 

, ,.rv iiniK.ilaiil out. r ••xpftOMon at the trkwfw. FlnaUy. while the main 

I isi'. I Vx H r fX the ,«.rt«Xrthe e,t««.l condyle, tht- .n.all '''<;7';.' 
while intriKlucing a comi.lie.t.ion. would inadequate, with im-t o.^ ralois. fo, 
the !Moaia;ion of partB on the innernide of the woiiml. u i. .!>,..,» 

gi^ir'i WiM r'*'"" ol OUtar'f Inctoion.' With the . IIk.w Hex.d i.. alx.nt 
I.Wde«w^. ananrfttlari<ieiHionislM.gunat the. xtemal supra . ondylar r.dg. .me ami 
rhaHTTv;" iXsa bovo .he line of the joint .and in eameddow«war.lH.,,raetu ally 
parallel to the axis of the hum. riis, . 
vertieally downwards to llu' of the 
radius, ami from thenec alonj? the outer 
lionler of the aiKoii. iis to the iioslerior 
border of tlie ulna, three iiuhes Im I.iw lh<- 
tip of thi' oleeiimon; linally. tin- incision 
teriuiii'tes bv curving Inwards over the 
inner surfae.-" of the ulna. This incision 
falls in the interval betwei-n thoae miWJie* 
supplied by the musculo-spiral and those 
Hupplied liy the iKwterior interotwoouti. 
SuliM-quent muBCular atrophy is thus 
avoided. The externa! lateral ligament 
with the attachments of the ext. iisor ten 
dons and the capule attached to the 
i-xteriial c.didyle, are w-jKirateil by a raspa- 
tory. Thi' (ori arm ' an now \h- completely 
disl<Maled inwanls. It complete resection 
is ih'sireil. the iiiteriiiil lateral ligament is 
separatci! along with the iniiscles from the 
bord. rot lh<- ulna and the internal condyle, 
and the end < '.f th.- Uiiies are removed. 

Method by Two Lateral InaWOM. 
Both Oilier and Heuter have employed tU» 
method hirgcly. esiH-cially advocating it in 
caxcti of ai&ylosiit. It is also strongly re- 
commended byChejTicandBurglmrd* both 
for escision and eraaion of the elbow-joint. 
It if) dencribed in the account of the latter 
operation on p. I <il ■ 

Treatment of Gunshot Wonnds ot 
the Elbow-joint. The strurture of the 
joint tenders it impossible for the 
capsule to be injured without injury 
to bone. As in the case of gunshot 
wounds of other bones and joints, 
the •x|>"rieiicpa of the South African 
\V;u diffi r considerably from those of , , • • 

previ(;n.s campaifjns, both as ref?aids tlie nature of the injury, the 
treatment, and the prognosis. With iiiodern high velocity projectiles 
a Btinple perforation of the joint may occur, or there may be exten- 
sive comminution involving the articular surfaces with severe lacera- 
tion of adjacent soft parts. The latter are by far the more serious 
injuries, especially as, in the majority o.' instances, they are septic. 

» Optrttitv Surgery, third Eng. Ed. by Stiles and Paul, p. 314. 
* Man. o/Swy. Tmrt., pt. iv, vol ill, p. U». 

Till. 81. Kochcr'a incision for 
excision of the elbow. 


Lt.-OoL Hickwa ' eoHcoted fnrty-nine cmch of Kiinxliut iiijur>'(i( Ih*' ollmw-joint. 
thirtvrn of which www of the niifiin- iif imn- |ifrfnr»tkinN. thf 'nimiiiiin| thirty-nix 
>M'ing vitbt>r coniminutiolM or tiHMim-<l fructunn t-xttmiling into thf artirulatian. (M 
the tint group iiino wen- uwiitii-. and of the InttiT only tliri'c. Only one chimi 
t«rminat(><l fntnlly, iiml thm iini|iutittion wiim iN-rfiirini'il for );'»>Kri'iic. which 
•njeam to hiivo been cuiiHt'd, oral any rati' rontrlliiitiil to, liy (lie ii|iplication of a 
pIlMiter of I'ariH ciiHinff. 

Treatment. "In the aw'iilif and in the Ifjw scriouM w'lilic caws llir tn-atnicnt 
wan dir(Tt«'d to ktvpinK tlu' wound aH free from infi't tloii as |h>mnIIiI(> and |ilai'iiie 
the liinli on Huilalilc N|ilintN. The total nnnilNT of coinMiiuutcd frai tiiri's wlilch 
recovcn-d without rcrourw to o|M'rati\c mcaHnrcN was only fight. Tlii' remainder 
wer« HUlijcctcd to o|M-r.ttivf interference of some Mort : thiw^ in wveiiteen. fraKnients 
of the varioUM bonni were wmovvd. of which mimlH-r Hflwn wen- Hcptie, one aMe|itie. 
Mid one doubtful. Inciitian for the eTaeiwtion of |nm. without further meaMurei* 
being rrquiied, was iH-rforincd, and waa foUowed by recovery in ow cane. Exviiiion 
of the elbow-joint Ikim Ut-n reported in wvcn caam. bat in two of thene ampntatioa 
waH Mubaequentiy carried out on ai eount of nccroMi and auppanition. Ampatation 
of the arm wan n'(|i.ireil in seven < as4 s. in two of wliich an ummccemful exciiiion had 
previously iHM-n (KTformed. and one died.'' 

Mr. (i. H. Makiim- does not mention any eases in wliieli excision of the elbow- 
joint was iK-rformed. He writes : • Injurieti to tliis joint ' came second in freipiency 
in niy ex|ioricnce to those of tlie knee. Tlicy were, in fact, eoniparatively common 
cHpecially in conjunction witli fractures of the various iMiny prominences sur- 
rounding the art i<'ulat ion. Kracturesof t lie lower end of the humerus wereof worse 
prognOHtic Nignilicance than those of the uli ■.. on account of tlie greater teli(hlii'y 
to aplintering of the hone. I saw Hcveral cases of pure |H'rforatlon of the olecranon 
witkoat any MignM of implication of the elUiw-joint. Several cas»s of suppuration 
whicli eame under my notice did well. 1 aaw one of them, aix months after the 
injury, with perfect movement." 

fturtUl InWni. The value of this fiperatinn has been disputed. 
In cases of disease it should not be einjiloved as, in addition to the 
probability of aiikylosi-s. it is lii<ely that the i)art.s affettcd will he iin 
perfectly reinoved. It slioidd be rejected for the treatment of 
aiikylosi.s at an un.sati.sfnctory anolc for e.xi ision of the l<»\ver end of the 
hunieni.s alone will not permit of i)ronation or supination afterwanb, 
as the radius and ulna are iirndy united at their Wjmtst en«k. 

In excision for injury it might be permissible to leave the bones 
of the forearm untouched when it had been needful to remove the ends 
of the Immerns very freely. The importance of .secnrinf; free mobility al ays !>.■ borne in mind. The .same conditions, which, after an 
injury tc. the elbow-joint, may interfere with a jjood result 
frorii forcible movement, will also interfere with success after partial 
excision. Thus osteoid masses may be formed by strip])ed-iip periosteum, 
a torn part of the capsule may be displaced between the joint surfaces, 
the articular surfaces or the ra liai, olcc ration or coronoid fo.ssa- iiiav 
become filled with fibrous ti.ssue, or ankylosis (lc\e|u|i at the superior 
radio ulnar joint. Some of the above c.;/. the luiination of osteoid 
■ leposits-will be especially marked in yonnj^ patients. Partial excision 
finis risks a result of incomj^ete value. ,.c. a joint of limited mobility, 
thot^h one, perhaijs, with a useful angle. 

xnc only cases in which partial excision of the elbow-joint for injurv 
U to be recommended are: (I) where it is nccssaix to excise 
a kuge amount of bone from the humerus. (2) Kxcisioii of a fractured 
?}Wondyle or ejHtroefalea, or fracture of the head of the radius. Removal 

* Ri/jI. OH Siiri/icil ("iin i in til' Soulh Afriain Wnr. 

* Stirg. Kxpi rii iins hi Soiilh IJririi. 1S!W HKMI, p. 2:it>. 

* Ai^arently aJl the injurieit were from buUet and not iiheB. 



ol thia process will be ■peckUly mdicated when it in nmclf out, at once 
or later on, to bo the cause of iMaited movement in the joint, or when 
it is the cause of prewure upon the ulnar nerve. (3) Some gunahot 

injuries (Dirfe Jtu/irn). .... 

Ezciaion o! the Superior Radio-ulnar Joint. Indirtttums. Tlits opera- 

sion may be, very iRcasiDimlly, iiiadf of, witli cvfry pLCiuitioii, 
in oki cases of ili.slottttioii of the head of the niditis. wiit-re rcdiutioii 
hM not been effected owing to (he amount of swelliti^, uiul where 
the movements of the forearm are much hanipred, < siM'cially in a 
young and healthy adnlt. 

Operation. incision ahrmt two inehes long is made over the 
projecting hca<l of the bone hcliind or throiigii tin- posterior part of the 
mipinator longiis. 

The soft parts having beon sejwrati-d with a hhmt dissector and held 
a«de with retractors, the iifck of the radius is can-fuily divided witli 
a fine saw or cutting boue-forceps. Sufficient bone must be removed 
here or from the external condyle to leave a gap that will avoid the 
risk of fresh ankylosis. The; museulo-spiral nerve lies to the inner side, 
and great care must be taken not to interfere with this or the biceps 
tendon. The forearm should be put tiirough its movements {m-e p. I >2) 
freely but carefuliv, whil." the patient is under tlie ai\a-.sthftie, so as to 
brmk down adhesions. Any needful drainage should be proviiied, 
and every care taken, by not interfering with the soft parts more than 
is absolutely needful, and by keeping the wound aseptic, to secure 
primarv union, and thus avoid the risk of stiffness again occurring. 
After a few days a sling may be substituted for a splint, and, ten to 
fourteen days later (nee p. lf>')). passiv nuivt'ments made of daily, 
with the aid of an ana;sthetic if needful. In October im Mr. Jacob.-;on 
excised the head of the radios in the foUowiog obecure and instructive 
caae : 

In the previous August the lad, agi-<l 12, lia.l fallt n from a laddcT on to his 
fwt, iMirtly on his right » ll>o», not on tlic hiimi. .Mat li swelling of the joint had 
followed, with suhseciuent stiffness, nndt ring the limb very uselcM. The foreaiTO 
was fixed in .i iiosition midw a v between jtronatHm and Hupination, and flexed at a right 
angle. Xo Hexion was poiwiblo beyond this. Paaaive extension powible to about 
l-iodegrees. Pronatioo and supination, B««ve and active, quite abohshed. A jmi- 
minence— ? the head of the radius— to be felt below the external condyle, but not 
admitting of loUtion : there was no crapteu. A diagnosis of tlisloi ation of the head 
of the radius was made, though against It were the history of direi t violem e and the 
absence of any nrtation in the swelling. On exploration of the injury by a free lateral 
incision, it turned out to be one of those rare eases of frai tun- through the neck of 
the radius. Just below the exteriuil eondyle tlic- head of tin radius was fouml 
sciiaiated from the shaft by a fracture through the upjKr part of t lie neck, and 
lyingwith its articular surface turned directly outwards. On removal of this there 
was distinct improvenn-nt in pronation, but little in supination. Flexion was now 
possible to 40 degrees, and extension t<> almost the complete range, but only on 
forcible movement. As the movements wi re still iiieomplele. and i ertainly would 
not be n-tained. 1 removi-d the capitellum of the humerus from the uamo incision 
with a narrow osteotome. The forearm could now be put through its full range 
of movements. The wound healed under an aseptic clot, and the ]iatient, on leav- 
ing the hospital five weeks later, had recovered ahnost complete active movemenU 
of the joint, though the whole limb was still weak. Three months later he could 
" do everything OMAy as before U» accident, and he cookl abo carry considerable 

Unfavourable Results and Sequelss ol Bbow-joint Excision. (1) Per- 
aiilence oj tuberctdom diseatte. This is especially likely when, previous 


to the oprution. tlio capHiil*' liaM brcn |M>rf<>riit*>(l ntiii disfiiso lum 
burr«>wetl out unionist tho (iriniim of thf H«-x<»rH <ir exteiiw»ni. 

(2) Carta and rknmic oMteo-mtfelilu. Theae Are not unlikely to 
mipervcne when the reparative power ia poor and the wound bfieomH 

(."<) AHkiflnsis. This is not iinromnmn in children, owinff to the 
Urciit ten<l«MM'v of inHiimnuitorv pnMluctH to orfiiuiiHt- i|ui( kly in early 
life. Furtherimm', tliiTP is th»' diHic iiity of p'ftiii^ tlifni to \\t»> tiw 
Joint or submit to passivf nKtvenuMit ; all they will do is to move their 
ami and {ormnn from the shoulder-joint. But thorough persevering 
treatment will aecare a aoand, tbuugk atifl, joint, with a vtvy aaefnl 

(4) A JIail-l ike joint. A limb may remain weak for Home time, owing 

to the nuLseles not taking on firm attarhments. Friction and pdvaiii«n» 
should he used perseveriiinly. II 'liere is t<M> much separation heiweeu 
the ends, the patient should wear ii well inoidded support ; the 
of the hand and fingers will thus l>e retained and, if the imtieiit is young, 
gradual and great improvement will very HIcdy take place in the cIImiw. 
He-excision and wiring may be tried in some cases with healthy patients. 
Most of the fiail-joints follow the extensive removal of the lower end 
of the humerus, especially in cases of injury. In such cases the i)erios- 
teum of the conilyies and the nuiscular attachments should lie as little 
interfered with as possible. Flail-joints are of two kinds: (I) Active 
flail-joints, in which the mu.s4 les are .strong and exercise control. These 
may be very useful, especially when aided by a support to the elbi»w. 
(2) Passive flail-jmnts, where the muscles are \vast«-(l. and the hand 
only can be used by the employment of a supporting splint. 

(5) Injection nj the wound. 

((i) A imless limb, owing to the nmsclcs being utterly wasted from 
long and disuse. 

(7) Injury to the uhuir lurve, with its resulting interferenie with 
motion, sensation, and nutrition. A few days after the excision the 
nerve should be found by a second incision below and in front, traced 
upwards and the divided ends united. 

(8) An eMerent tear. 

■BAflOV or TBI WLBOW-mat 

This operation has not been extensively practised, partly on account 
of the good results given by a carefully performed excision and partly 
because this joint does not lend itself to free exposure by so simple an 
incision as in the case of the knee-joint. Erasion is especially indicated 
in children, but in the elbow, as in other joints, it can only be |)erfectly 
satisfactory if performed in suitable, i.e. earlv, cases. Where the bones 
themselves are not diseased, eranon will give better results than excision, 
but tuberculous disease of the joints, and among them the dbow, does 
not always come before the surgeon in its early stage. 

Mr. Clutton, at a meeting of the Medico-CLirurgical Society ' advo- 
cated early erasion of the elbow-joint in place of late excision. He 
expand the joint by dividing the olecranon. Nine cases were thus 
treated. Of these the first two had ankylosed joints, but very service- 
able limbs. Six cases resulted in more or leas movement in the jmnt, 

> Bril. Mt4.Jomrn., Dee. 16, 1893. 


with rosHiition of tho diwas.'. Tho ninth nnd iiwt ras.- wa.s sii».(«'.|u.'n)lv 
exciMd. After cnwioii there is alvrayn a teiuloiu v to fil.nuw ankylosis 
between tlie en^ o( the bone« which ue left. Now t his w n«it u mattor 
of mneh importiinro in tho lower extremity where a firm wupport, an 
little shortcnwl ns ixMwihU'. is the rhief print to be atUmed. In the 
rnso o{ tho oilM) on tho oth. r han.l. oomph'to removal of the 

.liHotwo atul free niobiiitv slionl.l 1 ur aim. 'I'h.. latter eert'iin Iv - 

and tho former also with tho majority of operators will \»- l.ost 
attained by excuuon with free removal of the oimIs of tlio lioiios. N. xt 
to thomniBi expoMire and oniplete romoval of tho .lisoaso. a fn. lK 
movable joint is what we re<|uirc here ami, if tbU be attaine.1. it mat tors 
vorv little if tho limb is shortened. . „ . < 

Operation. Tho following account is taken from the Manual ol 
Surgical Troatmont." vol. iii. j.. -JKi, by Cli.'vno ami BnrKharrt. It will 
be noticetl that those writofH speak ^iiar.lodly <.f th.- amotiiit of mr.vo- 
ment which may be expected afterwards. " .Xrtlir.H tomy in cliildreii 
is an extremely satisfactorv oiK>ration. ^Iiieh generally loaves a r oitain 
amount of ovemont. althouRh the i. *'..nU!<>n of function is not oom- 
pleto ThooiM'rati«misbostperfonnc< ..>.i>-ii tNwu mR lateral mei.Hioiis 
..lie or. either sid." of the joint. On th , •.■.. the incision ahouW 
reach from just below the point at wl.i. • he ili '• nerve pierces the 
internal intorniu.scular septum .lowiiwa- ■ r, two or three inches 
IhsIow tho level of the j.>int. < »n the on. . . »u- . : • incision may cvt.-ial 
slightly higher up the arm, but must not roach as h>w down on t he 
f.)roarm for fear of injuring the posterior interoaseous nerve just opposite 
the neck of tho radius. It is as well to make the incisiona aa free a* 
p<)8.siblo because plenty of room is re.piirod to enable the Burgeon to 
.see cloarlv what ho is doiii};. The incisions are carrietl down to the 
condvlos of tho humerus, and tho removal (.f th.- synovial m.-mbiaii.' 
from" the back of the joint is i.r.K-eedoil with. Th.> . ajisul.' can usiiallv 
be readily defined especially u|)on the outer side, and tho skm and 
subcutanooiis ti-wues are raised from it by a blunt dissector. 1 ho w hole 
of tho cai)siil.- over the radio-ulnar and radio-humeral articulations 
is thus pradiialh sepnrate.l as far as the ed};e of tho olecranon. The 
triceps is also laiso.l from the capsule as far as the iniildle hne of the 
joint, when a .similar p ucedun- is ad(.i>to(l ..n the inner side, care U-mfi 
taken to raise the ulnar nerve from its groove bohin.l tho internal condyle 
along with the soft parts and not to injure it. The fingers can tlioii be 
ina<lo to moot arr.iss between the triceps and the capsule, and thus the 
whole of the u|)por part of the svnoml membrane is easily separated 
and can be divided bv a kiiif. just .,t its n Hoction on to tho bone, and 
peeled carefullv downwards : it is also divided on each side in the hne 
of the incisions, and is cut awav below at its attachments to the ole- 
cranon, and to the radius and ulna. The entire jiosterior portion of the 
synovial membrane is thus reiuove.1, and the no.\t atop is to deal witl. 
the anterior portion. In order to do this satisfactorily it is generally 
advisable partially to detach the tendinous origins of the muscles from 
the condyles of "the humonis, beginnin<r over the outer one. The 
periosteum is incised and 8tri|)ped forwards together with the muscles; 
these structures arc pulled forcibly forwards, an &.s.sii5tant holds the 
hmb flexed to a right angle, and the anterior surface of the ca^ule is 
defined and sepaaUed by a blunt dissector and the fingers. Special 
care must be takm not to daouge the posterior interosseoua nerve 


in the lower part of the incimon. The structures on the inner Bide are 
then dealt with in a similar manner, the pcnosteun. and the tendinous 
orf^ns of the nu.Hde.s bcin.^ separated from the .nterrml epicondy^e 
and the capsule detine.! and «'P««t?d from them. The fin^«^n 
soon be made t.. pass across fn.n. one inc.s.on to the "{f " Jf**^ .^^^ 
capsule and the suVrfi. ial structur.-s. amongst which wdl th« 
artery. The entire front portion ..f the ca,.sule can now be separate, 
and may be mt across at its attachment to the bones and can be re.noN e,l 
whole. The lateral ligaments are divided in «1«>"'K th.s. and the ends 
„f tl... bones .an then l>e easily protruded through the wound; the 
olecian.m is first nushe.! thnnigh whichever mosion it can be made, 
r , o e,, fn.n, ..,....> easily ..nerally the outer- and the jnovial 
membrane of th.> arti.ulati..n is completely removed. The 
orbicular ligament will also r.-.,,nre caiefiil insp.>.t..,n. f..r 't 
diseased. After all the synovial ni.'inbian.' has b.M-n r.;moNed roin 
its attachment to the W. an.l after any portu.ns of cartilafie or bone 
that are aff.oted ha%e l)een shaved off with a knife or freely gouged 
out the humenis is pn)trude.l through one of the wounds^ generally 
the' inner an.l examin,-.!. Sp... ial att..nti..n must be paid to the 
olecranon an.l coronoi.l fossa-, un.l tlu- articular surface must be treated 
in a manner similar t.. that a.lopt.-.l for the b..n."s of the f..rearm. After 
the disease has been thoroughly reim.ved. tli.' bon. s are replaced, the 
wounds stitched up without a drainage tube, tli.' usual antis.'ptic dremngB 
applie.1. an.l th.' limb placed upon an internal angular spUnt. 

• After-treatment. The splints should be retamed for three or four 
weeks, after which tlu' arm shoul.l b." k.'pt in a sling for •nother two 
or three weeks, and the patient .MK..urav'e.l t.. move it freely, {npre is 
no particular advantage in p.Mforming passive m.)vement f he only 
form of passive movement that is really desirable is rotation of the 
hand, andtUs may be practised diligently, both actively and pMWvely. 


A Simple fractures. ()perati.)n sh..ul.l b.' the rule, a few days after 
the injurv, unless at.'.! bv the want ..f any separation l)etweeu 
the fragments, bv some constitutional c.n.lition or by tin- age <)f tfie 
patient In the 'first case the diagnosis may Ije only possible after a 
nT.iiographic examination. Otherwise firm bony umon is very ini- 
pn.bable owing to (.») the wide separation of the fragments brought 
about bv the tri. eps ; {b) th.' interposition of torn portions of the 
a|K)neun>sis ..f thin mii.scl.> b.-twe.-n tli.- fragments; an.l {<) tilting to 
the ui)per fragment. The sub.s.M,u,.nt tibr<.us ,im..n to c.nsi.h rabl.' 
deHcieucy in the power of exteiisi.>n of the joint an.l c..nse<iuently ..t 
serious disabilitv. It is especially indicated when both ..l. < ran..n |.r... 
ha v.' Ii.'en fra.tiir.Ml. or wh.-ii a patient, in addition to a fracture of one 
oil", ran.m has a fra. tur.' anywhere in the other uppr extremity, thus 
ren.l.-ring him v.'rv ii.'l|iiess. .... , . i- » i 

B r„„nH,uHd {rorlnns. ll.'r.- tl p.-rati..n is .li.stinctly indicated. 

The fre«' inci.sior re.juir.-.l will r.'li. v.- th.- t.'nsi..n ..f tli.- .•.•.hymos.". 
soft parte, it wih aid ihe needed asepsis, it will admit of th.- r. in..val 
of anv detached fragments, it mil enable the surgeon to empty tfie of cht, which, .'ven if it do not suppurate, wiU persist tediously 
and impair future movemeuts. 


V In mme M-Oandimi jrmiurvs. orifjinally tr.-at.Ml l.y splint**, where 
treat m. nt is wmpht «m account of the resultrng wt-akn.'s-s. 

It inav lu-ri' be inentionod that, when for any reason, opeiatmn ,s 
not ,,e.f..nne.l. no time sh..ul.l be wasted by atteu,pt8, usually fu • 
to .Jaw .town the upper fragment with strapping. The ease BhouW h- 
assidii..uslv treate,! fro,,, the first xnth w.- 1-apphe.l ...assa^o. H this 
£ ntelUgently currie,! ..ut, the wasti,.f. of the tr., eps a„.l other n.uscles 
S^ n Ake place, the elTuse.l pro.huts are '(""^'y "•'-f^'; 'j'" 
the a.U,esio„s in and abmt the joint are prevented. I he sph,. s leit 
olT aft.-r a few davs. the patient then carries Ins an,i ,,. u shnj: mid begins 
to use it cautiouslv. The .esult is excellent far less irksomeness 

oJntiMI. The parts having been most ca.efully cleaned the 
sur^TmSesa con'-e.x Hap. the ski,, su K.,,ta™ 

andthe olecranon bursa. The incis,..n begins a i.ttle above the h-Nc 
o the fracture. alM.ut one inch to one si.le of ,t and .s then earned 
d,.w„wa,ds and curvwl acn»ss the back of the elbow about one „eh 
I'elow the lower extent of the olecranon, and then h"«lly carried up 
upon the opposite sid.- to a , op,M)site to where it »»«f»n- /[he 
."miexity of the Hap is thus .lire. ted downward. ; care must be taken 
that it is of even thickness throughout. r <• • . i : .1. 

The Une of fracture is then made out.' anv to,,, eds;es of f ,s. .a winch 
„,av lie iH-tween the fiagments are turne.l as,de and trunn.ed .lean 
u{ n..t rcnoved ; th. joint is fully fle.xed. a,.d any . lots !"^ked out 
or washe.l awav with sterile saline s|.lut.on. To carry ^e wmnR 
a s.nall incision is n,ade vertically d.nvn to the ulna, a full half-mch 
below he line of fracture. The cut ed^^■s of the per.osteun. are at once 
S with s„.all clip forceps, to mark the spot and to obviate one 
Sltv i,. l.assi„R the wire. The heme is then dr.He.l obh.p.elv w,tl 
drill of sui able size, the ,>oint enierpng <m the articular surface j«.st 
el„d the articular cartilage. A second small vertical '"^^^ « t^en 
„,ade with the same pn-cautions through the periosteum ..f the upper 
a M.u-nt. and it.. ed«os sei.ed with ^.rceps. The drill .8 then npim intr,.. 
ted obii,uelv so as to n.ake a,e for tl,e exae ly "Pl-.^'te to 
the first. ThcKrcHtest care must be take,, .n dni ,„}: these holes that 
thev exactly corresiKind on the f,actured surfaces, e.xac^t appos, 
,io,-, will not be .secu,v,l. Steriliseti silver wire is the, insinuated thr..u«h 
the o,M-ninirs in the fn,>;nicnt«. and the forceps wh,.h a. t as ^.ndes are 
t ri.nov.;i until thisTs .lone. Full Hexi..,. o the joint faalitates the 
passage .,f the win-. The joint is now finally washed out with hot 
Ss^'d .sidine »..lution. the f..rear.„ is extende.l. and an assistant 
brini:s the fragments accurately t<.«ether by pressure with ^' l"«y 'J 
st..riris...l «au«e in each hand. The surg^m. |frasping tin; ends of ho 
wire in stninji fonops. straiuhtens them and kt^ping his hands |..w 
,„.kes a sn.ali: neat twist of about four half turns. Yhe emls. ...t si..., . 

„„.„ l.,„„„ere.l .h.wn into the an.l bone. I,.- 
should be cmpletelv bmid by sutunnn oy.r th.-,n with catj-ut an> 
fLia or p,.ri.«teum"that is to han.l. .\nv lafral ^aps „, tne .apsule 
,re .■l..s..d in the same way. The skin is the,, sutun-il an.l as a ruh-. 
,'0 .Irainajie is r. -piin.!. An ..n,ple .Ins-sing should be applied, but no 
. ,„. . , . ,.1,,,,., i„i I'll' til i.f ilir iil.i liiiion iiiiiv lie l>ri(ki'ii iiiTj 

he .1. la. Ill il lit iis junukm with the ch^t <A the hIba. 



splint is niTPssarv. l».ia»ive movemente should be conimciKod in about 
a w.-. k juhI iiuissa>i.< as wmn as the stitches have been removed The 
i)ati.-iit i.iav l«- all..\N.Ml to miov.- the joint himself at th« end of a 
fortiiiuht. but iiw (ISO should not bo ixTuiitted for five or six weeks. 
In oW-8tandinB cases the operation will bi- upon sinular lin.'s. but 

o\vin<; to a<llifsious havui(i forincn 
between the upper fragment 
and the olecranon fossa of the 
hnments, antl owinp to the 
great separation brought about 
by the action of the triceps, 
fl\>nt diHiiulty may be ex- 
perienied in drawiiin the fra}i- 
nients together. This may be 
overcome by h-ngtliening the 
triceps. The method of effecting 
this is incbcaled in F^{. H2. 
Mr. Walton' suggeiits as an 
ini|nii\rnii'nt a metliod similar to tliat 
atlviM Mti'd l>\ f.oril liister for olii st.iiid- 
iiij; IractiiK ~ nl the pa'ella - 

FiMtoret ol the Coaiftet id tbe 
Bf nm These injuries. «iiefa timmyM 
involve the articukr surface, are. wt^m 
the fragmejitj* are accnmMv repfeiced, 
verv likelv t<> be followed by s.-rious 
disaliilitv Killier condyle inav be frac 
tnre.l. It there may be i T-shaped 
fracture, in whit h the h>wer e.xtremity of 
the humerus is separated a verticiri 
line of fracture extends fmm the tarn- 
verse line to the articnkr snrface. "Rte 

tip III tl pieondvle Mia\ also alone lie 

frai tiiied, in which case the jmril is not 
opened. A thorough and carelul radio 
graphic examination is essential for the 
diagnosis of thes«> iM}uri<is. and also to 
y!uide the .surgeon in the treatment to 

lie adopted. 

An atii-nipl mi.i\ .it lir>t lie made to 
manipulate tlie fni;;nieiits into position, 
the patient being aii;>'stheiiseii. 

The arm should then be put up in 
the fully flexetl p<isitifm. A second 
radiographic exatnination shouhi always 
net satisfactorv. open o|M>riition. if not 


Fill. H-». Sh-thiMl ii{ fc-nirllit tiiiii; 
the Iriri'p" ill ill'- I'l"!'''!"" '"' 
wirinu I«hiv *f.iiHiini: t ~ "f fiat' 
(iircol iIm- liiii'iii. lh< Lui!' i 
liitun- r,li.««s till- Um-i Blip n-- 
ijhiumI fur ex|McHn- «rf the lrii «'|i». 
Httfl the rXTrHte.! clivi-inll ■! i\v 
nmwie <l<'«'fit>f<l lli' i' \' ' 
-iii.ilirr tiii'in >li<i»- til' iii'llioil 

lit ,l|l|iniMllli>l ItIL' till' ~i lMli"ll^ 

«Ik.\' iiii'l Itlnw. anil IkiH I If 
I. t..itir»<i-<l. THp apii-ei. 
of tic .M iLiiiunx are nimfc' blunt 
inontvr to wMtire ii UrK<-r »tt»fw'«> 
(iiriiiii"n. |!'hryi*"mil Biirtfhunl.) 

Im- lliadr ;l!i'' it llie position I 

CiWftruili'li. lied li\ ^:'_'<' 1'^ -oiiie (■oli>t it lit loiiid ci illdit loll, sliol 

certainlv l«e advi.scil. It i.iiot lie reiiieniiieied in an iniportaiit 
j«»int. stich as the ellM.w. a very tpHing im-gulaiit v of the articidar 
sur^- mav canse nuich limitatioti of nwveinent, antl alwi that callua 

* iyi-y- Opi 'itioHnfor t'mfi«ti '■//*< PnUUa. 


or orteoid nmsses formed liy stripix-.l up iM-rioBteum may 8ubKe.itiw»th' 
aerioody interfere with the mobility of the joint. ... , 

Opmtkm. The fracture nnwt l» frwly expose*! either l.v u 
vertical median im ision over the bark of the joint, or by a lateral wnmni 
alonii the mipra eondvlur rid^'eH of the hjunenw. The fwnner mm>m 
is be«t for .lealinfi xvith a T-shape.l fracture, while m s.-paratio« of .me 
condyle a lateral in.ision mav he emplovc.l. Two hiteral ineismns 
mav b«' made if neeesMarv. wh.-n the soft parts rim\ I-- s.-,,;n,iic.l ron, 
the capsule in front and behind (»« dewribed U.v Kn.sio., p. IM). 
Care must be to av«id injury to the tth»r oi musculo spiial nerve*. 
In thlH wav a free exposure oi the fracftur.' ami of the jiant •••«>• 
obtained. With eith.-r ini ision. after the s.ift parts have h«H« r.-H«-te«. 
the joint is opened and all l-lno.l clot w.ish-.l ..uav with Htmle mhm^ 
solution. The fragments are now mampiilatcl mto <i>h^ p.«m«»i ai«l 
BCfured bv a screw or by a small Une s plate In the . as.- -.1 a T shap.-.! 
fracture the two snuill fragments shotd.l first l,,' a.rurut.-ly litt.-.l to^. t her 
while the lower extremity sh.mhl In- fix..l t.. the shaft Wvm^«H <► ' 
.small plat.-. On« of L«ie'« tfee«e-liiitbe«i i»lat4« may *w e«^fc«".i i*^- 
this puriMise. , ^ 

The rent in the . apsuh' is th. n . lusd l,^ a l.-w . attftlt »mmre« «»d the 
WHind clos...! An iiil.Miial angular splint slioiil.l l>e applietl, care IwMin 
token that th.- vesMil w frot* ai «he f*«iW ao' no* e«»iwto»!*e«l by tma 

M bandaging. , i i »i 

Tantiotwpasstve m«wiiBen«« inm- lie st«rte.l in a ».-ek. whde u<-'«M; 
»a«8j.L- shouhl coin.n. n. . -las s„un a« the stiti'hes 4»*e Ihhmi reni..v.-l 
gepwation oi the Wer Epiphyas «l tl» SMHi. I«» < «'rta.n . as. s. 
where reduction ..t tli»- .|ef.,rmitv is iiH|M.sKihl.' or in .^ne ohl-stanUin>£ 
cases where the mobawv ..f the j.-m. is seriously iifh-iU;\. ..(M-ration 
may Ik- called f«if. it • ^rri.-.l .ait ..n tli.- lines .i.-s. r^be. a ...v I h.- 
apiphMis is exp«d ^»«# <«»e ot the al...v.-.l^fd*e.l ilKlsiolls 

i^n^ed into positkm. mA mmmmi by a plat.-, wire, ..r staple. 

Thr«ftei treatment is also sitnilar. Sir A. Lane aiU mm remo val 
the nlm- as ,s.H.n as iini<.n has .M-. tirred in all ca««» of BweiaM^l hxa- 
tion of epi^hvses ..therwis.- u.t.-rf.-n-ncc with growth, leading to 
«|ueiit liciuniiiT is likclv |i occur. 

Ur (. y ..I l1nla.l. l|.liM.a.his.'|,H.t..liiy..f theh«iw-riwfc«^^ 

wrufc lh.- ,1. fornutv whu 1. may foll..w a fra. ture «f the inlefiw! WMKlyle 

tin,. ..f H.- I.H.ks a|K.n iWm w tfcr m>^ «»mn«m of fn.rt«rfs 

waJi:. aild the t««e .-KpH^-l hv .-Hrefal .liss.-. i..i. H,. ..,.,..„. ..hmv he«n wr>f Ik. th.- outer side ari.l m fn.nt i -h. ..v. i. '„ . ' 

Hnd Wiind this iiM-iHion. Th. ... t „.H,n.M...v ...^ 

narrow .mteoloiiie in int««l... . .l ..H.I tin 1 .hu.l. .l Ian n., . ... l. f . 

tftmurnkT ii. Ae«,-.l ..r l«nt .iniil .L- .l.-i'v-' c.-."-' - ' ' / 
Hwb i. kept ex*™le.l ill i.laM,r..f l"..n^ f... -v • •> ,' "',1,,.,,^ 

w«B«gi>Hnd movenK-nt ri-»t..r. ih. M...iHlity ..I II...J..H11 II. t ' " 

BW Hi*** with Mienttsful nutthK.' 

Arthroto»f. Opening' th.' .'U"." -xm* ni»«- In- calM for in the 
foUowinK . ..n.lilioi..-* : (D K-.i .iiai.....;, in .ases «l -Hftj^ratfve 
arthritis. This max 1..- t!. h suI. a pun. »ttle4 

origin r.') Fi>r the removal of loose *'^Ll!li*'' *fc- 

,,ie< es ( hipped from the articular surface, the mm* ^ mar^ 9» 



»v b»' »'fferte<l hv two iiuisiims. one on eHth 

of the dpcwwn. Tht proximity of th«> ulnar nerve nuist »«; i einen)_ 
hered when making the roner iiiciMon. Ftet^t free irr^ticm with 
sterile saline soluti»)ii ekioM be vwtmik^, or HWrorMon the i«ew 
in an Lull uiiiiUiiiimrt " tonmc kite or mmm aotatoen nMjr be 

.he elbow shouW l>e flexe.l to a ripht aii};!.- an.l the forearm kept 
m^KftV between full pronation aiitl supination. Passive nioveinents 
Iiioillll'ln' I iiHiiiiwiiinwi tmrir us ankvUim is verv hkelv to follow Not 
infrwiuentlv howewrki=f!WMBi«; caiw^ «^ially lu ehildreti. miri)risnitrly 
U00.1 movement is obfenwiii. For the removsl ofHwise heitm an mnsion 
on the out.T si.l.-. nvv tii.' Iiea.l of the ra.lins. m rccBWBiended. A 
fr^nent tietacheif from the artieular surface of this bone w one of ^ 

Indicatums. Thouph not very fre<|iietrt4v p«ifnnnmi. ther e we a 
number of conditions in whieh this i^ra^on if« strtwitly inrtiM*Bd. 
Generally speakinjz, tiiese ar.' ciiaraeten-ed In rwl weak, irften 
irregular pube of low tension ,. lahoiirmc anu .tuaietl right veiitnole, 
and backward pieawue ah>nf: tin- svst.-..n.- \.ins Dr. Heddard says: 
" In extreme cases of cardiac diktatioi .^i.>-< tion nmy be an alm ost 
necessar)- preliminary to enable the overrtietehed muacle «• M^^OBd to 

^italis. 8trv( hnine,"and other cardiac stimulanta." 

The following aie the chief indications : (I) fn mm» cases of chronic 
bronchitis, especiallv when an acute attack exau^i.-ratcs the chronic 
fomble leading in rapidlv in- reasin^j cyanosis and canliac failure from 
over-^irt«HR«i of the ligilt aide of the heart.' 

(2) In some cases of injury to the lung and pleura and of trau^tic 
pneumonia. Captain F. J. Porter. R.A.M.O.. r<*rte» a ca«5» which 
illustrates the truth of the above remarks: 

• A li.utennnt was Kfiot tliroiiKli tlir ( hot iii Him t amUiiKli. He wiis pirkeil 
lip four liours lafrr in a rritical < (m<liti<in. <>« iiifr tt> .Ivspn.i a fi..iii ,i large effwrton of 
hlooil into the right i.liiirn. Twenlv four hours later. »hil. tli.' |iatient ww* bt'ing 
taken a. ross .ountrv to H. ill.ron. Ilie livi<lity Ueuim M> gn-ut and the pBlsc fallwl i» 
iiiiK h that ten oiine. s of ver>- dark bImHl were taken from the median tewlic vein. 
The iwtieiit iniiiiediatclv tunusl on hi» wounded nkfc- and wi-nt to rteep. Next 
morning he wkh <(uit.' rational. Fifty miU-s were trekked in twenfy-ctght and a half 
boon. The r»-eovery was uninternipled." 

In cases of acute lobar pneumonia, (twing to the tendency tocaidiac 
failure, venesection will be very seldom indicated and shorid owkf be 
done after consultation with a physician. 

(:<) In severe cases of cardiac valvular disease, when the heart is so 
dilated and engorged that the right ventricle can with difficulty contract 
ut)on its contents. 

(4) In Bonie severe epileptic attacks, esjM'cially the status epile|iti( us. 
a moderate venawction is »l service. In severe urainic (onvulsions 
the fits may be arrested in this way. though can- must be tiiken not to 
draw off tcio much blood. It has "also been employed with advantage 
in the treatment of jmerjierHl eclampsia." 

' \crv inti ri-Ktinu |ini» r< (with ^n^l■s) will U< i«»r.<\ l>y Dr. I'ye Smith {Mtd. Chir. 
Tnnis.. \ U.\iv. |>. H). Ilr. 0«le»nil Sir.S. W ilk» (tfliw*?. >-oi. i, Itftfi.^- U3»>. 
< A;rt/. Mtd. JoMTH., vol. i, 1801, p. 054. 
> Dr. ThoBua {Brit. M^.Jown,, im, vol. i. p. 400). 


(5) In anonrvsius. osperially tl...nicic. a small amount o! 
blood should be withdrawn, though the treat nu-nt may. A ^^eces^»ty^ 
be repeated. Vene«5Ction here undoubtedly relieves certain very 
troublesome symptoms, via. dyspnaa and pwn. 

Operation. The skin havinn been eleamwd, t»>^*'«"* 
i„ a Ifttin, ,K.sition. an.l a banda.e tied round the middle of tueam 
with sntticient ti^'htness f. reta.d the venous circulation ^"^t*'?"**^.^ 
that in the art.-riea.' the surgec.n selects the ineilian cephalic or tne 
ml^ basUe'whichever is n're prominent.^ Steadying this ve.i by 
Em his left thumb upon it just b.'l<.w the ,,...nt of intended puncture 
S^th hL ripht h«dWiai steadily upon its ulnar --f-'"'. ' J^^ 
the vein with a snmll. Aaip sodpri, acmpulouiily clean, making w th. 
a uentle sweep of his wrist a small inc-«i. and not a mere P«"ct«r^- 
Li! the vein. ' The anteri<.r wall of this being divided, the 
BMiPtratinu anv deeper, is thrust onwards, hrst increasing the rilt m tlie 
v^rT. Ind then be.nj cut verticallv. care being taken to make the skin 
wound Unter thiw that in the vein. The thumb is now raiscl and th. 
TtZn SedIL the me««H«^el.» While the bhH.d is escaping 
IhTZd, shouhl be ke,*rthe«i«^tion leat. by the skin slipping 
over the wound in the vein, the bloo*«houW be ptewente*«Mm Liiipmn 
freelv and thus make its way into the cellular tissue 

The required amount of bloo.l having been withdrawn, a "^wih^ 
thumb is Jaced on the wound while the han.lage is ..moved. A small 
vTol asJnt^c gau« is then placed on the puncture, and secured with 
fbandagc appUed in the figure <.f H. This pad may be remove.l m 
abourfJMIht hoar-, and for a day or two the patient should use a 

"'"'Difflcnltieg during and complications after Venesecttoa. (1) tt^g^y 

in findin.' a vein. This mav be due to their small size, the fesMBncw 
of the c.rculati..n. or the abundance of fat. If a vt"'". ""f 
sufficiently diatiuct by hanging d..wn the hmb. Pitting it 
flexing and extending the wrist and hngers, ami chahi^? the limb. on. 
E.1.1 be opene.1 on The back of the hand or blood - J^d'awn J^^^^ 
..Nt. rnal jugular or mt.-inal saphena at the ankle. (2) In other tases. 
Xn the l.ent is mu.h; iate.l. owing to the absence of steadymg 
fat the nulbibty of a vein n,ay ..nabl.> .t to ■'v;>;M'uncturo. unl«« a 
verv sharp iiistrtiment be use.! and the ve.n well .steadie.l. W h. n 
the" vein has b.'en owwd, sufficient blood may nor escap.- owing to 
(rt) The mav be k mere puncture. (6) The skin opening may 
J insutti. .. nt m size, or not paralh'l in pimition to tl,*t «. the v.....^ 
Th..e imp...iHn<.„ts a... ren.ov...! I,v a freer une -[.^^^^^'^^^ 
ma.le or bv biinging th.' wound m th- v. u. prallel w*ll ti«t «• the 
skin T) .V p.-ii.-t ..f fat mav i.l'.d. th.' .,p.h.r,g in ttM" vewi. T»18 
should be snippe.1 away, (rf) The paf- nt eu.v fa.nt. A 
,uav four This will disappear when the current Ih-coiiu - more 
H(t.v.> (j) I'lie bandage may be tied too tightly round thr aruv 
14) Wound of the bra.hial -r son th.-r art^-rv an abnormal 

,ti. k 1 1' »* hi- .um. *=tr»H> hw Aou«htK. and. by ^»*ioli«JMWe^ 


ulnar. Tliis tan al\va\8 hp avoided by a careful use of the scalpel, and 
by noting beforehand tlie existence of any pulsation. The force of the 
jet and the mixture of bright with dark blood will tell of this accident. 
Pressure should be carefully applied and maintained, and blood 
taken from the opposite arm if reijuired. (5) Escape of blood into the 
tellular tissue. This will leatl to ecchymosia, and perhaps fonnation 
of a thninibus. which may be absorbed, but which also may suppunte. 
(C.) Phlebitis or inHaniination of the lymphatics. These may be caused 
by the use of infected instruments. Kvery i)recaution must be taken 
to secure asepsis, as any failure is likely to lead to the following two 
most jfrave results. (7) Cellulitis and septica-mia. (8) Intense pain 
in the linib, with gradual flexion of the clbow-jmnt. This is due to 
puncture oi the external or internal cutaneous nerves, which are con- 
np<-tp<l through the brachial plexus with the motor nerves to the brsciualis 
anticns and biceps, which flex the elbow-joint. The injured il«ve 
should be divided, subciitaneously if possible, or the scar excised. 

ELBOW (Fi^i. 64 and 83) 

This operation, (oiiiinon enough fifty years ago owing to the 
freipiencv of venesection anil the facility with which the brachial artery 
was wounded, will l)(> briefly described here. 

Indiratinns. (I) Wound of the artery, especially aft>r venesection 
or tenotomy of the biceps tendtm (here a ligature above and below the 
wound will be required), or a punctured wound from any other cause. 
(2) Traumatic anenr>-sni, whether arterio-venous or not, occurring after 
a< (•! lents such as the above. 

The hitr ciiinpai^ii in Smith .Nfrici .siw u pn-at inrrcBSi- in the rKrurrciKc of 
iirtrrio vcnoiis iim iirvMiii from the |ia.s.sanr of Uiflh vcloiHy Ijulli'tn of n siiiall 
riililirr lliroii>;h mljacriil .ntiries and veins. This sulijict will Ih' nfcrn-d to ut 
|i I'.M ill till- acrouiit of hKatiirt- of tlii' ;'.\illar>- aiirry. tin- msscI of the U|i|x-f 
( xticinit y ill wlilcli, arconliiiK to .Mr ( '■ H. Makitis. opemtivc iiiterft-rrmit! in most 
iiki ly to Im' iiM'ful. 

(iuide. The imm aidt! of the bicepti tendon. 

In Frmt i 

Skin: fa<« ' i' . bicipital t laiia; me^M 
hiiMlii M'iii. Hnnit h>.^ of WlMBid and 
e.vternal «'iitaniH>us nerve. 
O m tai i e huside 
Bic«^ Ivitdon. liracbtal artm MediM nerve 

Vena coium. at hmk «f cf hi nn Vena cmem. 

Mnii liuih.v anticu^. 
Operation iFigs. lil ainl s:\). The hiiiK IxMog stfadieil, ".vith the 

• 'lliiiW .sli^htK lli'M'il >lfi' 111 till ti udoii shiilliil 111 i(<'|i|i,.(| 

ami al.'Mi tluil of .no >.iii:<' veins. Iiy nuikii ^ I'lessure a little almse the 
priipiisi'ij site (if he ligature. All inciMioii about two lUid a hull >»Hhes 
long IH then iiitide. u little ti> the inner nde of the bic<^ tendon, tbroii^ 
the supernal fasria. curefHRy, so as to avoid the wedba tiHutic v«n 
and its ( (iinpaiitiin the interiml cntaneous nei^e. If thwk- am twea, 
they must l)e drAwii inwards. The deep iaaoa it> then ^vidtod, b«t this 


and the semi-lunar fascia of the hicops. whidi stron>;th.-ns it. should ho 
interfered with as httk as iKwsibi.-. The nrt.Tv. with its vnia- | ()init.'s. 
lies directly underneath. The needle shouhl h.- imss.-.!. aftor th.- v. ins 
are separated and the artery cleaned, from within out wanls. so as to 
avoid the median nerve, which lies more deeply and to the inner side. 
In the case of traumatic aneurysm, arterio- venous or not. resmtrng other 
treatment, a proximal lipature placed as near as po.ssi hlc ul)ov'e the sac, 
or the old operation of placing d(»uble lifjatf.rcs.- will he preferable to 
the Hunterian one. which runs the risk of ov.•llookln^' the jx.ssi bilitv 
of a rather higher division than usual of tiie brachial mto radial ami 

F»n . h;». l.iKi»u»«" ol thi' bntohMl •rUtry »t the boiiil »l «Im elbaw. 

ulnar If much hwrnorrhaRe in expected, th** bfa<'hi»l sb«»uUl !»• coni- 
piesw'd alxml the iBid<Me tte am w*A •« b»odafee i»r a 


Tke meeUu huMr vein wM. in BMMiy nMi« «• 

■ U M be iiw ilfiil te pMtrm^' tli.- inciHhm d.iwnwar*. «• «« to wwww "f*""'''^^ 
thn fwital or lAuir, tlie Kcipital tamivk nni«» <Hv««l moo" fpxJy. tlw mo^m 

liasilir vi'iii M'CurtKl if it f-annot Ix-drawn t<)<>t>-- si<l<-. 

■! (til this iui>l nil "tlwT artrrM.-v.-niiii-. «M-,irv-.ins Ih. hIm. i ■ Mr. M.ikinK. p. I 

vliMiilil !«• -liidii ■< It •»*' i" 11 » li.' i>r. l. t< ir'al of it |m>Miiml '.j;iH.»tv tirBt. H a 

1.., il ,,,„ > iiinii I f UM.! I.. I"- <ll"l. li^iitiin- will I* iwtiiimi ttbevf m\A IipIuw the 

. .,iimuinitati..ii hiiI. th.- w in in tlir . ..f .,i,. „rv .mal v.wix. uml iiIh.v.- m»\ '»•» ■» til- 
»•(; if th« wiwa ■■ ihieiin with » v«ri<H«<> aiK-iirv-m. I' •"■»> l.. iM-tl- r (tlx ■»rt«ry 
Mnii .nmmarfod »h<>v' i to open tli.- «*•. and th.i-. tind ili. i.|. -.tiM. - mt. ili- »rt«Tr 
l,v thr aid .,f i Hiimll Ikmi.^i.- As Mi. U..ln.. < l.s'-/-' -~-\ hi. | . 'XZ. ;-.,i,t- -ht. 

liir ..lli.T plan nf ait.-uiptMi^ (,, l,i,d .u„l . „ll„. rt. r> »,lh.M,t ,,,,.„urj th- - > ..r.«.-nl ~ 
llir.s,. dirti.ulti. . VI/ Ilia. 111. art.TV v- -,i. r..,„„i.-.l l.s .lilatid and -^.w-ly |nu k.d x-ui«. 
and ilm. I--!.- 11..- ,* r is ..' ,„mll Kv-ry pnfftutKm bejalum t»ji«M» 

tin- waui vvm. If " *jn«*»b«B« '^j «>< "««*• "toWw by panMVP. In? j^wtiMrt, r 
ligMHfe ..:«>aU be MtcMpMd. ««ty, 
tied kbove mnI belMib 

Uw *«te be 


aneurysm, be found nmch dilated by the entrance uf arterial bl<HHl. 
Occasionally it ban been obliteratinl. In ordinary traumatic aneurysm 
the sac shuuld be ti.t away with wiaaon aft«r the artery above and 
below ha8 been secured. 

TIiIh operation at the haul of the elbow should always ho performed 
with tlu' utmost carefuhu'SM at the time, and paina taii.-n witii the after- 
treatment, so as to ensure the minimum of disturbance and the smallest 
anxmnt of cicatrix, aiul thiw to interfere as little as poHsible with the 
inovementa u{ the elbow-juint. 


USATUBB or BRACHIAL ARTERY (Fijjx. H4, h:» an. I 

This is performed («) in the niitUUe «if the arm ami. inii< li mcr.- 
ran'lv. {h) at the bend of the elbow, the operation last il.'Hcn»MMl 

(«) In the middle ol the Arm (Fijj. H.")). Imlichom. (I) ChieHv 
wounds of the pahnar nrch. resistiiiji pressure (•««■ p. H'.t) 

(2) Wound of the arterv itself hv a |)ciiknife. Imyonet. I.ullft. i'(:c. 

(3) Gunshot wound of the elbow, leading to seeondary hii in<.rrha)je 
resisting other treatment. 

(4) Angeioina of hand. 

In March IWM Mr. .laci.l.soii tiiil first the hra. liiiil. uiul, tivt- nMMlths Inter, the 
rmhiil imd ulimt ait. ri. H for a . onBenital angrioma with m"*"*!/'*^'''^.. ♦'JT 
atfecting all the lingem ami the i«ilin of the hand m a girl aged IH. By the fiwt 

Kill. icisiiin for lit'.if iin' nf tin- lir.u .uli rv. 

nix.ration the va,s( illa, s C|.ii. klv recluee.1 ; the se.-.u..l. M.le.l j.V eat(JlH >«'toi.s. 

WHS followed l.v vi rv .^.-d Hkriiikiii«. and. iiltiniat< ly. a eoniplete eun-. A full 
a.eounl of the cam' 'with the ret^ult tii: yearn after the o|M-niti..ii. ik given in the 
(>uy'« Hotpital RrpirtK, vol. Ivi. 

(5) W ound of one of the arteries of the forearm, followed by severe 
hemorrhage, a sloughy condition of the parts preventing ligature of 
the vessel sbove and below the wound. 

In the year IHSi' a (uitient rame under the rare of .Mr. .laroli-nii fnr »e. oii.lai v 
h^BWiillimi fioin a wound of the forearm, iiilli. ted by the lnir>tinn of a uiiii in 
raak-dMoting. The imrt.s were mueh swollen and sloiinhy : tli<- ulnar artery in 
its nrid^ third, from which the ha^niorrhaKe was roiiiliiH. was jrr. i ni.-li ni . oloiir. 
Mid appan-iitiv not in a eonditioii to hold a llnatuiv. .V pHxl re.(.vrry. with no 
lurthfT hemorrhage, took place after liKatiire of the hiacliial m the nmUlle of the 
arm In l«S.-> it was foutxl iie .ss^irv again to \\y this artery, for ha'morrhage 
,H . uiTii»« n iH-atedK a f. w dav- afl.-r a Bupimrating i«ilinar bursa had U|en opeiu'd 
in the u*ml way. atnivi and below the anterior annular ligament. Thi« |>atient 
tceeveml with a wvakenitl limb. 

(#) Tmanitie Mtd sfOBteaeouB aneurysm. In traumatic aneurysm, 


whfthci- of the luactiial nr tin- artfrics of the forearm. (h>> <>I<1 operation 
if prcfriaMi- to the II lllitviiaii. a.i tlif sjic is often iiii|t»Tf<Tt (we alto 
remarks on p. I7:{ on - Abiioriiialitii« of tin- Hrachiai Artery "). 

Dr. H. Boiisiiiiet rt>€on|g' a caM> of traitiiiatic aneurv8m' of tlM 
forearni. datinj; to a nuiinliot injiirv. cured l)y excision of the sac. 

.\ hiliDiinT. uliil)' iMuichin);. nrrivctl ii charge of li shot, which, entering in 
ihc liiwcr ihini <'f the fiirciinii, {nismhI (>lih(|iiely upwards ahnoHt iih high i%» the 
ellxiw. 'I'hi' UKiiiiil heulcil n|i in alioiit six ueekn. Kvidenct^ of an aneiiryMin liecnmn 
nianifcHt thirli'cn ilavi after the iiijui\. hut o|HTative treatment wax rpfiwcfl. Six 
nioiitliM after the accident, an KHHiarch m bandage having U-en applied, an inuiiiion 
WM made over the MweiUng. which wait now ^ a pj^iihinB ihaiie, and naobed 
from the mkldle of the ann to (he lowFT third of thefofewm. Tm bfacUal artnjr 
having been tied a« low down a* pomnbie, the anrarysm waa wiMualed from the 

Fio. 8S. Ligature of the brachial srti^ry in iIh- iniildli- of th. , rm. 

«<li.;'cnt siriicliuvs. In spiti' of nnieh caie. its wails, which were very thin, ra • ■ 
wi^y .It -l u nil s|»its. It.s iiili ii'ir was lill<'d uilh |Kixi«ive elot. It8 lower e^'-. ii'iiy 
w.iii i iiil» ili!cil III thr . II .itiix of the uoiiiid. The aiienrx-»m prolmbly 8pi:iii); 
the aitnii-.s of the fon arm near iheir iriu'iii. |» rha|>t« also fn/m the lirach.. ! i he 
ri'Mio, il of thi' .iiii iiry in left a larjrc rnvity. of which the HiMtr wiis formed hy the 
iiil. r'is.s<oiis iiicinl)i.iin . .tiiil t!ic sides Ipy iiiu.sclcs of the forearm. Several vcsm Is 
xv.i. ti. d l« foic .111(1 ifii r the ii iiiinal "of the Ki'iiiareh's Imndagi-. A» it wiih ini- 
iH - ~i I'll' to 111 III.: ^o^f a vmiuihI to^c t her. it waa ph^ged with iockiform game. Tb« 
|iatit lit ici 'ivcn d with a useful limli. 

With rejranl to sj)«>titatieojis Hiieurvsins. it is well known that th«f=e 
ire ve!\ laiv ill the iipi>er extteiiiify, aiid usually assiuiiited with cardiac 'A heii this coiintiicatioii is present, ligature will only be thought 
of when the amairymu w rapidly increasing, or caomng painfni preasure 
upon a lu'rve. 

Loral antPtrtheHia may be useful here. 

' Cniigregt'mii. rf. fliir.. \H\K, p. 741. 

' Theaneury»ni iit hI>u> ilcM.rilied iw orterio-vei uuh, but nu vvidvucc uf this ia given. 
The acwnmt of the veswla affected ia practically nil. 


Line. From the junction of thf middle una ant. rior of the 
axilla nlonjj th.- iiimT odft'' <>f th.- rr.ruco-bmchiulis aixl bK-ep*. to the 
middle of the elU.w-triangk. This line is of .-siHTml ''"P«rt«f«. when, 
owing to tbe radKng. *c.. the edge of the bioe|» m difBcult to make 

""^(ginrff The above Hne •nd the inner tdg^ of the btcepa. 
BehHmu in una. . ^ 

In FrmU 

Skin ; fasoiie; bfandH-s of intenwl and 

external ctttaneouH nerves. 
Median nerve' (about the centre of the arm). 

OtUMide '"""^ 
Coraco-brachialis (above). firuihiul riimrnrrv.-. 

artery Tntcniiil t utaweouH nerve. 

Vimaoomea. in arm. Veiia lomeH. ,. . , . 

Baaiho v«n Buperfn-ial t<» 
deep faacia in lower half, 
beneath it above, umially 


Triceps (middle and inner heads) ; coraco- 

l»achUilia ; l»achialis anticus. 
Mnactilo-Bpiral nerve and superior profunda 

artcrv (above). • r *k 

CoUateral circuUtion. (</) If th.- 1..- placed above origin of the 
superior profunda, the vessels chiefly concerned will be : 


The subscapular ^^j, ti,,. guperior profunda, 

'^''^(inif the*Ugature be placed below origin of the superior prof unda : 

'I lie radial rfctirrent. 
Till- |)(istenor ulnar recurrent. 
The suprior profunda with .pi^^. i„(,,,,,,s.seoiis recurrent. 

The aiiastoiiiotica magna, 
(c) If the ligature be placed below the inferior profuiula : 


The radial recurn iil. 
The anterior anti piwterior 
The superior profunda ulnar recurrenta. 

The inferior j^onda -fj,,. interosseous rec urrent. 

The anastomotica nia<;na. 
AteocmaUtiet. These ar.- so far from infrequent that the surgwm 
must be prejiared for the following' : 

(1) The iirt. rx iH iny m front irf tlie nerve. ^ . . . . „.«.... 

•> \ hiiih division tlir an. rv. Aceonling to Qu«n.m one out of everv hve 
oaH, s then- were two arteriex instead ..f one in some [Mirt. or m the whoU-. of the arm. 
The ,«int of hifiination is thus .lesoribed by Gray: " t js frequent n the 
up K-r l«»rt. less so in iJ.e lower part, nnd least so in the middle, the most usual |H,m 
for the Bpplieation of a li^a.i.n- : under any of theee cireuniHUnoeH. two largo 

i The mediMi nerve i. to the outer side ol the artery »t iU ^""^n^^^'fj'"*** '* 
Mffioi*^ the middle ol tha mrm uul i» tu Um inner ud« in tbe tower Ulinl. 


arteries woulil 1r' found in the arm instead of one. The most frei|nent (in three 
out of four) of tlu-Mt prculiiiritit-H is the liigh origin of the rnitiiii. Thnt iirtory nfteii 
ariHTH from the inner Hide of tlie ImirhiiiX and runx |Nirallel witli the main trunk 
to the elbow, where it croswH it. lying beneath the fawia; or it may jierforate the 
fawia. ami iwhs over the artery immediately iH'neath the if'egiiment."' ' 

(;<) The artery may lie |iar(ially (■()v<'red by a innseiilar slip jjiven oil fn>m the 
|M'etoralis major, biceps, eoraeo-braeliialis. or braehiaHs aniieiis. 

(4) Instead of follou in^ its uisual euurse along the braehial antieus, the brachial 
artery may a('eom|iaiiy the median nerve, liehind an e|iiconilylic [trocctis or tign- 
ment. as in many l arnivora. 

(.">) It may also jiive off a vas aberiaiis or a nieiliari artery, anil any of its onlinarv 
branches may be absi'iit. The vas aberrans usually ends in the radial, sometimes 
in the radial recurrent and rarely in the ulnar artery (( 'nnnin}:iiam). 

Opention (Fig. K.~>). The arm being exteiuled Mid ubilueteil from 
the side, with the elbow- joint flexed ami supported - by an assistant, 
the surgeon, sitting hctwccti the limb and the trunk,^ makes an ineisiim 
thicc iiiche.s in h-iiL'th along tlie inner border of the bicep.s. beginning 
from below or above as is most convciiicnt. going tlirough the skin and 
fascia', and exposing just the innermost fibres of the muscle.' This is 
then (bawn outwaids with a retractor, the median nerve next found 
and drawn inwards or outwards witli an aneurysm-needle, aiul the 
artery defined and sufficiently cleanetl. when the ligature is [>assed from 
the nerve. In doing this the i)asilic vein and the vena; comitea, which 
increase in size as they ascend, must l)e carefully avoided. 

It may be lieio pointed out tiiat the brachial artery is bv no means 
.so easy a vessel to tii' as might be supposed from its superficial position. 
This is especially the case when the artery is concealed by the median 
nerve at the point where it is sought, and when its beat is feeble and tlie 
vessel itself small and but little distended after repeatetl ha;nn)rrhage 
lower down.* 

AMPUTATIONS OF THE ABM {¥ig^. ><7 -!)()) 
IndicatiODi. Amongst these are : 

(1) Accidents, compound fractures, machinery accidents, &c.. 
which do not admit of any part of the forearm being saved or of amputa- 
tion at tiie elbow. 

(2) New growths involving the forearm and not admitting of extirpa- 

(•J) Disease of the elbow-joint not admitting of excision, or in which 
this op<>ration has failed {see pp. l.">(>. Hill). 

(4) (lunshot injuries of the ujiper part f)f the fon-arm. elbow, aiul 
arm not admitting of con.scrvative treatment or excision. 

' The |Mis.sibility of this superlicial iHisition of the rndial or ulnar should always he 
reineniliered when venesection, or ligature of the braehial, at the ellMtw is nb«Hit tu be 

^ Mr. Heath hait ininted out {Opir. Surg., p. 18) that if tlu' arm. uIh ii at li^iht 
angles to the iHKly, beallowe<l to rest up<in the table the trici ps is pu>licil ii|i. ami lli^|lla<•in^ 
the parts, inav brinu into view the inferior profuiidii and tlii' ulnar ii< r\c iri>li'a(l of the 
brai hial and the median nerve. 

•' This is a much nmrc comfortable pusition than standing on lln- und r side and 
loiikinu over. 

' -Authiirit ies differ as to this step. The operator is si nmyly advised to avail himself of 
this guide. If it can bp done car^ully, and the wound kept aseptic aftcrwanls, it l an do 
no harm. The fibres of the niuwie are a distinct help, and (as state<l alnivi>) li;ralun> of 
this artery is not so easy a oni' as it would appear. 

' This was so marked in the latter of the two i ax s nicnlinui il at p. 171. that, when 
the vessel was e.\|K)sed, several bystanders felt certain that it was not the brachial, but 
one of iUt bnnohra. 

Klo. Wl. AiWHtomosing branuhcs of subclavian, axillary and brachial aiteriei. 


Amonpst the sporial conditions which will havn to bw consiclorcd 
here art> tho size and cliiinictiT of tlic projot-tiK*. t!u' {gravity <»f the 
huTratioii of the soft parts, tho ainotint of loiifiitiuliiial spiintfrinjj; of 
tho boiios, tho oxtoiit of losioiis to tho vossols and iiorvos and tho doftrce 
to which conservativo nioasuros can be ado[>tod in tho uhsoiuo of hospital 
facilitios or of easy transportation. 

If the surroundings of the surgeon and patient adnii^ of it. attempts 
will, nowadays, be made to suture tho nerve ends, especially when only 
one or two of tlio chief trunks aio inv<iIvo(l. Hoforcnco has already 
1)0011 ina<lo to tho infro(|iioncy of .sover(> };unshot injuries to he elbow- 
joint in tho South African War. 

It is noteworthy here that Mr. Makins writes 

" 1 mil unable to Bay what wax tho pro|iortionAl nambcr of shell wnunda nnuiiiB 
the men hit. hut i can Hay with Home coiitulent^i- that it was not as pn-jit ns Kt |ier 
cent. I Nhoiilil 1k' inclined to piaee it as low as .'» |mt cent. A^jairi, I cannot ti.x 
the |>ro|>ortioiiate (M'ciirrence of wounds from Iiiiliels of Imni- calilire, such as the 
Martini Henrv. but tliis was certainly not larne. I think if lo imt cent, is dediii'ted 
to repicsent the ni:inber of hits from either of these forms of projeirtiles. thai we 
may fairly assiimo the remaining IK) jicr cent, of the Wimmis to have been |iio<liii e(l 
by ballets of small calibre."' With regard to tn-atment of woumled joints 
Mr. Makins states (p. :;:!.'») that this was generally simple. "The ohi diniciillies 
of di-ciding on partial as against (complete excision or amputation was never iiu't 
with by UM. We had merely to do our first drcHsing with care, fix the juinl for a 
short period, and lie careful to commcnco jiasBive movement as soon as the joints 
were projKTly healed, to obtain in the great majority erf cases perfect results. If 
sujipuration occurriHl, the choice l>ef»i-en incision and amputaticm had to be con- 
sidered. In the early stages this chi. (h'lM-nch-d entirely on the nature of tlie 
injury to tho bones. If this were slighi incision was the bi-st course to adopt. I 
saw several cast-s so treatetl which dicl '. although convaliwenee was often pro- 
longed, iuid only a small amount of m<)\ iiient was regained. Amputation was 
sometimes indicated in ea.>«'S of severe Inme -plintering when the shafts were impli- 
cated, but 1V8 a rule only |K'rformed after an ineffectual trial to cut short general 
infection of the septieaiuio tyjie by incisioiu I shoukl add that, on the whole, 
suppuration of the joints was uncommon, except in the case of injuries f^ exceeding 
the average in primarj- severity."' 

(5) In some cases of acute septic infection of the forearm, when 
septicaemia or toxic absorption threatens the patient's life. 

So inestimable is the value, even when only partial, of the hand, 
and so good are tho results of consorvativo treatment ai 1 sooondarv 
amputation, that the tissues must ho almost disorganised foi tho surgotm 
to think of primary amputation hero. 

The following case illustrates the power of recovery after very 
extensive injury to soft parts : 

A man, a-t. 22, was admitted into fiuy's Hospital in Xovember liHl with a 
large transverse gash just below the right "elbow-joint, caused by a fall through a 
gla»8 window. The severe hemorrhage was checke<l by a toiiniiipiet applied at 
once by a policeman, but on arrival at the hospital he was almost pulsehss. Tlie 
whole of the soft structures were divided down to the bones, the elbow-joint being 
o|Mnied and the head of the radius exposed on the outer side. All the superficial 
ticxors of the forearm were divided just below the internal oondyl,*, and also the 
supinator longus and the tendon of the biceps. The radial and ulnar arteriea 
Were divided at their commencement and also the common interosseous. The 
median, radial, and |K>stcrior interosseous nerves were severed, the latter, just at ita 
I<assage t lirough the supinator brevis. The tendon of the biceps and tlie muscles were 
sutured, though it was impossible to hlentify the variow ramcular bellies. The 

' Siirijioil E.r,.. ri, «r..- 1« South Afririi. 180!) imKl, p. II. 
In the pre-. I I war the (jruiKirtiiin of shell wounds is certainly much greater than in 
the .South African War. Uwing to the conditions of trench warfare, too, infection and 
■uppuntion are almost certain to occur. 



iiii'iliiin iiiul niilial iii i vrs wen- also iilciitilii'il aiiil Niitiirnl, Imt luiiiNHlcnilili- clifli- 
(tiilly wiiH <-x|M-rM-iU!i-<l in uh'iitifyinK t\w iMwtrrHM' iiitcniNM-oiis as it was lii ii' KivliiK 
olT a iiiiinlN'r of iniiwiilnr brannlM-M. Thi* injunil urtcrirH wen- ligatiin il. Kxi'i'|il 
for the MknighinR irf n lnr|{t' InoTattil urea of Hkiii on llir fon-iirni Im'Iow tlif rllmw, 

thn wnnnd iK'uhil wi-ll. The function of tin- niiMlian an<l radial mitvik wiim r vcnil 

and thcri^ was ^imnI inovt'iiiriit, tuul wnxiilion In llic Hncrrs. Imt nwin;; tn the 
srarrliiK in fronl «f (lie forcariii, tliiiiiRh tluH was ininiinisi'd as far as |«issilili' l)_v skin 
^raflinx. full extension of tlie elbow was ini|Hitu<ilil<'. OwinK to I lie |M'i'siHtenee of 
paralysis of the extensors tlin posterior interosKooUH norvp Wiut t(li'ittci|Uflltly eX|NiM»'<l, 
diHw-vtiil fret' frinn the s(wir tiMsiu- and HUtnreil. 



I'l.i S7. A. Amputation throiiiili shoulder joint !>>• di ll oi.l flap. Amputation 
throuL'h arm livloii-ant. riorand short ,K«tU.riorHaiw. B. Amputetmn tlin.u«h 
am. hy the ein ul ar nietho.1. SpetiK '.s Mioth.Ml of ainpiltotinR at the shoulder. 

A CDmiwniiKl fnicttin'. ospcciallv whon commintitcd utnl associatfd 
with sevi're lacciatioii ..f tli«' soft aiwl division of the main - ossds 

or norvos will jiiohal Iv ie<niif.> a piinuiiy amimtation. thoiifrh even in 
some of these cases conservative tifatiiieiit may he tried. 

Methods. (1) Circular. (::) Skin Haps with (■iiciilardivi.sioii of muscles 
— («) antero-posterior ; (6) lateral ilips. l-i) Ai.tero-i. .bettor Haps, 
usually cut hy transfixion. (4) Skin and transfixion Haps comhined. 

(.">) Siiifile fhlj). • t r I 

(I) Circularmethod (Fii;. MS). >wiii-.' to the moderate mze of . 'iinb, 
its cylindrical shape, and its siiifil: centrally situated bone. thi. is the 
^e, abftve all others, where this method can be employed, especwUy 



in limbs whirh iirc not very buikv. Whether he make use of it in after 
life or not. tli)> stuilont ghould always practise circular amptttatioo here 
on the dead subject. 

Standin<; on the outer side of either limb, the brachial artery having 
been controlled by a tourniquet placed as hi^h aa possible, the surgetm 
with his left hand draws the skin up strongly and passes his knife under 
the arm. then above, anil so around it. till, "by dropping the point verti- 
cally, the back of the knife looks towards him, and the heel rests on 
the |)art of the arm nearest to him. A circular sweep is then made 
round the limb, the completion of this being aided by the assistant in 
charge of the limb, who should rotate it so as to make the tissues 
meet the knife. A cuif-like flap of skin and fasciae is then raised, 
for about three inches, with light touches of the knife, these being 
especially needed along the lines of the intermuscular septa. In a very 
muscular arm it may be difficult to raise the skin as directed, and it 
will be sufficient here for an assistant to retract it evenly all round ai> 

Fio. 88. 

it is freed by the knife. When the skin has been sutticiently folded 
back and retracted the muscles are cut through close to the reflected 
skin, the biceps being cut rather longer than tlie rest, as, owing to its 
having no attachment to the humerus, it retracts more. The cut muscles 
are next retracted by the operator's left hand, and the remaining soft 
parts, with the main vessels and nerves, are severed clean and square.' 
The bone is then cleared for three-quarters of an inch and, the periosteum 
having been divided, is sawn through as high as possible. 

The modified rirciihir method { Fig. 89), as described for the forearm 
on p. 140, may also be employed. 

The vessels to be secured will be the brachial upon the inner side, 
the superior profunda in the musculo-spiral groove and the inferior 
profunda to the inner side of the brachial close to the ulnar nerve. The 
wound should be sutured so that the resulting scar is in the antero- 
posterior plane. 

(2) Skin Flaps with Circular Divitkm ol NuAt. This method should 
be made use of for bulky muscular arms. 

(a) AtUero-poderior Flapg. The brachial having been controlled,* 
and the arm supported, at a right angle to the body, the surgeon stands 

' In an anipiitaticm which passes through the muacnio-spirkl groove, gmt cue ma*t 
he taken to dividi' coniiilctely the nerve lying in this before the bone is sawn. The depth 
of this ^.TDOvo varies miieh. When it in considcrahle. the nerve may easily escape division 
and Im- fruyeil liy the saw. (jivinj! rise, if overlooked, to a most painful biillHius end. 

> In amputation high un the application of a tourniquet may be impossible. The 
axillary must then be eontroiied by efaMtic tubing m described on p. SOI, or tte rabokviaa 


outside the right and inside the left liin!). with the forefinger ami thiiinh 
of his left hand niaricing the site of tiie intended iHine-section (Fig. W). 
He then enters the knife on the side of the hnih farthest from hini, 
carries it first down three, three and a half, or four inilies, aecording 
as he is going to make this flap longer than the other or not,' next across 


Kio. 80. AmpuUtionof thi-arni by the mmlitiiMl oirriilrtr iiictlioil. 'I'lii' tlnttfd 
line rt f in A IB the ordinary inciition in the circular inethwl, while tht- thi<-k line 
a h e mHows the mcHlified rimilar incision. The skin flapH are Bhown in B a» 
well as the circular iliviHion of tlx- inii.srIcM. 

Two equal flaps of skin nnd .Milx iitaiu-ous iissin' arc rut, their lower limit 
being, in the ras«' of an onlinary forearm, about I A iiu lies below the seat of the 
circular division of the iiuiscles" and then atjiiiii about 1 1 inehes l)elow the point 
of section of the Ijones. In the arm each of these nieasiin inents will Ik- inen'ast-d 
to 2 J inches or more. After the flaps are raised, the muscles are divided by a 
scries of circular swwps of the knife. After eaeh cut they are firmly n'tr«ct<?d 
until the bone is exposed at tlin (iroposed point of division. The jxTiostenm 
having been divided circularly, it i» stripped up with a ruK'ne along with the 
muscles. Thus, when the l)one has In-en sawn, a cap of (MTiosteum falls over the 
cut end. Tlie muscles and iHTiosteum must be stripped oil thb bone together, 
not separately. (C'hoyne and Burnhard.) 

the limb, with stiuare edges, and up the side nearest to him, to the 
point opposite to that from which the incision started. Then passing 
the knife under the limb, he marks out a posterior flap, usually somewhat 
shorter than the anterior. These flaps, consisting of skin and fascia?, 
are now dinected up, the muscles cut through at the flap-base with a 

must be contnAed bjr a reliable assistant, or the vessels secured by gpence's method. The 
latter which is described on p. 206, is, owing to its simplicity and reliability, strongly 
recommended. ■ n i 

• Long anterior and short jHjsterior Haps are iireferable: it eepial. the eieatrix will tie 
opposite, and perhaps adherent to, the bono. This is undesirable, though of less im- 
potUnce than tai the lower extieraity. 


circular swocj), mul tin- bono wiwii tIiroii<;li as lii;rli as |M)SHil)lf. Tlie 
biceps hIiouM Im' cut rather loiifrcr than the other nnisc le.s. and especial 
cjire .shouhl he taken her(> to divide the iiervu-trunkH cleanly and a« 
liijih as po,s.sibk\ In tvinn tht! arteriea each must be thoroughly 
separated from its acconipanyinj; nerve. 

(6) Lalenil Flup.s. This nietliod may be employed. <ine flap beinj; 
cut loRget than the other, when the skin is more liama^ed on one Hi<h'. 

The Burgeon, standing as before, marks the site of bone-section b\ 
phicin^ his h'ft forelinfier and thumb, not now on the two borders of the 
arm, both on the ini(hlle of tlie anterior and po.sterior surfaces of the 
limb. Lookinji over, he enters liis knife ut the latter spot, and luts 
a well-rounded flap, ending; on the middle of the anterior aspect, and 
then from this point, without removing the knife, another flap m marked 
ont by a similar incision ending at the middle of the back of the iirni. 
The flaps are then dissected up, and the operation completed as beff)re. 

(•'<) Traiuflzion Flaps, usually untero-BMterior. In an arm of 
moderate size, or where uipidity is reiiiiired.'as in warfare or in cases 
of double amputation, this method may be jnade use of. The objection 
to it is that it involves the removal of an undue amount of bone and, 
where the amp-.itation is hifih up, interferes with the preliminary securing 
of the brachial artery by Spence s method. The surgeon, standing' as 
before, and with his left hand marking the flap- base, and lifting up the 
soft parts anterior to the humerus so as to ffet in front of the brachial 
vessels, and thus avoid splitting them, sends his knife across the bone 
and in front of the above vessels, and makes it emerge at a point exactly 
opposite ; he then cuts a well-rounded Hap, about three inches long, 
with a quick sawing movement, taking care, after he feels the muscular 
resistance cease, to cany his knife on a little, so as to cut the skin 
longer than the muscles, the knife being finallv brought out quickly and 
perpendicularly to the skin. The flap being li<;htlv rai.sed, without 
forcible retraction, the knife is passed behind the bone at the base of 
the wound already made, and a posterior flap cut similar to the anterior, 
but somewhat shorter. Bf)th flaps are then retracted, any remaining 
muscular fibres divided with circular sweeps of the knife, and the bone 
exposed a little above the junction of the flaps. The saw is then applied 
after careful division of the periosteum. The brachial artery will 
either be found in the posterior flap, or if. as both flaps are made, the 
soft parts are drawn a little from the humerus, the main artery and 
nerves will be left, and must be cut square with the circular sweeps of 
the knife. 

If it be preferred, lateral flaps can bo made by transfixion, one, of 
course, being cut longer than the other if this is rendered desirable by 
the condition of the soft parts. 

(4) Combined Skin and Transfixion Flaps (Fig. Oo). This, a speedy 
and efficient method, may be made use of here. An anterior flap of 
skin and fasci.-e. about three inches long, having been marked out and 
dissected up. the bulk of the soft parts behind the bone are drawn a 
little away from it. the knife passed behind the humerus, and a posterior 
flap, somewhat shorter, cut by transfixion. The operation is completed 
as described above. 

(.I) Single Flap. The condition of the soft part.s iimy icnclcr thin method 
Bflvixiihlc. If iKWHihle an anterior Hap is cut by transfixion and so arranxed as 
not to include the large nerve*. 



In all cases of amputation high up in the arm some part of the inser- 
tion of the p(>ctoruli.s major should be pretwved in order to counteract 
the tendency to abduction of the stump. 


By the term " exciuon in continuity," deliberate removal of portions 
of the shaft of the humems — e.g. two to six inches—the periosteum 
being preserved as far as possible, is meant. If such operations as 
incision and removal of splinters, for neerosi.s. and for pseudo-arthrosis 
be excluded the indications are very few. It has been performed for 
gunshot injuries and possibly mi^ilit be required for a loeulised growth 
such as a chondroma and in some eases of necrosis. In the latter the 
surgeon will, in the great majority of cases, wait for the sequestrum 

Flo. 90. 

to separate and then remove the necrosed portion of the shaft by 
sequestrotomy {q.v.). 

With regard to its employment for gunshot wounds.^ Dr. Otis thus 
wrote in 1883 : 

" I cannot discern that the experience of the war lends any support to the 
doctrine of the justitiability of opf-rations of tliin nature except in very exci'ptional 
cases. The numerical returns, and the necessarily iiblireviutcd summaries, may 
appear, at first glance, to represent the results in a favourable light, but a more 
precise analysis reveals most lamentable conclusions. . . . The mortality rate is 
nearly double that observed in thcTases treated by exjK'ctant measures, and more 
than 12 per cent, higher than tlw fatiUity in a huger aeries of {wimarjr ampatatioiiB in 
the upper third of the arm." 

Free exposure of the shalt of the humerus is not easy, owing to the 
important vessels and nerve.s in more or less relationship with 
it. It is best exposed by an iiicLsioii coninieiiciiifx • the interval between 
the deltoid and the pectoralis major and contii led downwards along 
the groove to the outer side of the biceps as low, if necessary, as the 
U "sl of the external condyle. The bone is reached to the outer side 
oi the coraco-brachialis and the brachialis anticus. Care must be taken 
to avoid injury to the circumflex vessels in the upper part of the incision, 

' See also the iwnariu on guiubot woundi of the radius and nlna, p. 134. 


while towards its lower eiul the nui.sciilo-spiral ii"i ve shoulil l>e identified 
and be drawn, together with the superior prolwiula interv. the supinator 
kHlffuS, and trireps. to the outer si(h<. Tlie periosteum sliouM !»• e;ii"- 
fully peeled off the b<ine with the help of a sharp periosteal elevutor. 
The refjuisite quantity of bone is then removed, the shaft of the bone 
beinf; divided by a fine saw. 

Another incision sometime* piiii>lovt>d commences, as deseriwd 
above, in the interval between tl, deltoid and the peetoriilis major. 
Below the insertion of the ileltoid it is earned superfieially (so 
as not to injure the iiuiscuh)-.spiral nerve) till it nets into the interval 
between the triceps Iwhind and the brachialis antieus and suinnator 
longus in front, whence it is carried down to a point just above the 
external condyle. The nerve is made sure of by «)pening the inter- 
muscular septum and drawinR the triceps backwards and the brachiahs 
anti< us forwards, and then held ( iirefull\ aside with an aneurysm -needle. 
The .shaft is exposed an<l the necessary amount of bono removed, as 
described above. 

Canies of Failure after Excision of the Humerus in Continu' 

Ani(m>p»t these are: ( I ) Osteo-myelitis and pyuMuia. (2) Secon(hi. 
hemorrhage. (3) Secondary necrosis. (4) Non-union. Ieadii;« to a 
limb which dangles or is flail-like, and is more or less useless in spite of 
a support. 

Operative Treatment ol Acute Infective Periostitis. This disease may 
connnence either at the upper or the lower epi|)liy.xeal line. The jnis 
collects beneath, and strips up. the perio.steuin from the shaft. Acute 
osteo-nivelitis alwavs occurs at the same tinu*. Xecrosis of a part of 
the shaft is an inevitable sequela. In the acute stage one or more 
incisions, according to the extent of the abscf^s. must be made, care 
being tak<'n to avoid the important vessels and nerves. The medullary 
cavity should '.)e freely gouged ojjen in all cases. No attempt should 
be made to nove the necrosed portion of the bone until the sn|uestnnn 
is separated. This will occur in from ten to twelve weeks. 'I'lie opera- 
tion of sequestnitomy is then nMpiired. A free iiit ision is made, if 
possible, on the outer aspect of the limb, but this will depend v on the 
situation of the sinuses. The bone is exposed, the soft involucrum, 
consisting of newly formed soft jjeriosteal bone, is freely gougetl away 
until the se(|uestrum is thoroughlv exposed. 1 his is removed, and the 
cavity, often of considerable exttnt. is washed out with Int. liydro^'en 
perojcide. A few .stitches are inserted, but free drainajre must lie pro- 
vided and the wound allowed to heal by granulation a long ami tedious 
process. Methods for filling up the oavity and thus hastening the 
healing of the wound will be given below. Occasionally the periosteum 
of the entire shaft may be separated, which then is certain to necrose. 
Should this condition be fcnmd the diaphysis slioul.l be removed, but. 
unless separation has occurred, a small i)ie(i' of the .■>liaft adjoining 
the epiphysis should be left, to avoid injuring the cartilage at the 
epiphvseal line. 

OperktiTe TtMtm«ntof Fracture of the Humerus. This will be re<{U!red 
in some cases when it is impossible to get the fragnients into apposition 

by nianipulati(»n, and in those cases where non-union occurs or where 
tliere is injury to the musculo-spiral or other nerves. Tlie fracture is 
best exposed by a long vertical incision between the triceps and the 
brachialis antieus on the outer aspect of the arm. 

FHArrrHK ok tiik ih'mkri's n« 

Any intfr.-iMiinn portions of luuikK' <»r inM-ia. arc rt-diovcil. tin- fra^i- 
mpiita are brought into p<witi«>n bv extenmon and ur»> wn viretJ by a platt-. 
All iiit.Tn»l anKle apUnt u applied ; mawafie b startiKl as tumx an tli.' 
wouihI in h<>aled and the Btitchea are rpmoved. 

Oprraliim for IWuil„-,irlhr<»iiK. A fp.lw joint i» ii'>t an iiii. oniinoii si cin. lu to ii 
fiaetmv Wi\t th.- .. tiln- <>f the nlmft "f thr huMu iiis. It |.rol« ilt |« ii.lH u|Mifi 
Imperfrct in-nii.l.ilisatic.ti. t)|« niliv. ti. atm. nt is always rr.|iiirr.l. 'I li.- fntrluri' 
ia eximwd fm ly thionKli tlir loiin . xti rnal iii< isi<ni <l( w rili«-«l iil»«vf. A |Kirtnm 
each frauni.'Mt iiiii»t Im' i. im..v. .I I.v a tin.- saw s.i that thr »««tion mMHt thruuffil 
hcttlthv ls>ii''- 'I'l"' iifn sliiMl surfaiis an- then l.rought l(it(i>thcr and nwilKd l>y m 
iilatc. " WIkti' thcrr is niiiih M>|Mratk>n thU iimy lie impawible. An alttwiil may 
thon lit- inutU- to till ii|> this H|i«if by bont- gnifting (h* mjrn). 

In any of the above operatnnw. the treiitiwent oi thf |»t'riost. imi 
will 1)0 of \.'iv firi-at iinportance. Prufeiwor Oilier warns those who 
would <'.\p«'(t that |)priostpiiin niethodit-ally detached from th« bone 
will always iiii'l coinplotply rfpifMlncc the bone that it iioniiully covered, 
that thoy are iiih1<t a tlai.<;mtiis illusion. It can only be relied upon 
to do 80 in early life in voimj: subject«. and when ilieri' lias been no 
infective sappuration destructive to the iMine-prodiitinK lells and 
when some longitudinal splinters have been left attached within the 
periosteal sheath. If detached with a blunt elevator, the outer ejastic 
tissue of the perio.steuni is alone detached. When separated with a 
knife (»r a sharp periosteal elevator or ru<:ine. however, the inner bone- 
forming; laver and attached spicules of bone are preserved. When it 
is desired that new bone should be developed thia method of separation 
should always be adopted. 

In these, and in similar operations on the othe- lonf? bones, a con- 
siderable "jai) in the continuitv of the shaft resulting in non-union and 
a useless Innb. or a large cavitv in the bone which will only slowly heal 
by jiraiiulatioii. may have to fee treated. The following methods have 
been einploved. 

(1) Boi '/rajlitiif. Tiie bone retpiired to fill up the <;ap may he 
obtained from the patient himself bv chiselling away portH.iis of the 
same or another bone (auto-plastic ineth«Kl). or by taking |)ortions of 
bone from a freshlv amputated limb, or by making use of a bone taken 
from one of the lower animals (hetero- plastic methrol). The former is 
naturally of very limited use. 

Sir W.McEwen' recordH a successful case in which a hoy wlio had necrosis of the 
entire shaft of the humerus after acute iiif.i iiv iH iiostitis with a ust-lcss dandling 
limb, in whii h he praftc<l jHistions of bone dcrivcl from cases of cuneiform osteotomy 
of the tibia between the wideiv separated extremities. These tilled up the jtap to 
the extent of four and a quarter inches.the arm then lueasurint: six inehcs mlen({th. 
Seven years afterwards the shaft of the humerus was found to have nicrcasc il to 
seven and three-quarter iiichi-s. The iwtient could use his arm for a great many 
purpoaes— taking his food, adjusting ma clotlwis. and in many games. 

Sir A. Lane has recoided two cases in which he restored the shaft 
of the ulna by grafting bone from a rabbit. 

One case was that of a child with congenital maldevelopment of tlie bone. 
The ulna consisted of two separate imrtions, whose pointed extremities overlap|H<l. 
and whose axes varied considendilv in direction. l?oth were freely ex|M.setl and 
■eimrated from the adjacent parts. Kxtension was then made on the lower one 
until the hand was in normal position. The fcmnr of a rabbit was then split longi- 
tudinally, and its halves wired lO the fragments if the ulna bo as to bring their 
1 Ann. of Surg., vol. vi, p. 301. 



ax«n into iIm- normal lim- itn<l t.i nt uii lli-' 1' .nr oiip on n U-vil with IIm- radiuN. 
'\'Uv ri Kiill iiiiihI Katixfji' •rv. rmt only af< to tin- ili-(oniiity. but aliio brcaUdC M 
thf nmrkMl and |ini«nHHivi ■.|'irovt infiit In thi- uwfuliM^ of Ihf limlj. 

Till' HiToiiil dw wan thai of It man. mt. I». wlw iMd Inrt tlw OMt of nnp uln* 
two vt urB U-fon-. K»<liuRrM|>hic cxamimtion ahowrd tlie raMencn of a tiro- uplcu- 
htm Mwcni Ibr two nttvautka. An incbion rx|ioM><l thi- two mtU of t hr ulim nml 
Iho Knkiilp. MMl tnrd thi m from the adiaonit partw. The fc niiir of n v. ry largp 
niihit WM thro urcmrfy wir<'«l to the ••ml* of thi> ulna. Th«> n-ttulting limb wim 
much Ntmngrr than It whh liefon- th*- o|HTation. It in ))ointi<d out that m 8u« h a 

i!WH< ihi- pri w ii if WW »»ow thrown out at the ttwicr extmnity of the ulna, a i » 

rmult of tl ridiniil InMammatkia. ami aomf ankylonia ef jotaU may tateffw* with 

a iHTfi'd rc'Niilt. • J 1 J i. . 

In till- hitti r of thf twocaMm. howew, • weomn wh»q«ifntly dwtoped «lio«l 

the Kraftcil iNinr. 

Asn'ftanls tin- t«liiiii|in' of tlio <)|H»r8tion the jreatert can* must he 
taken to «f< iin> the m.)st rifjici awpHis. The grafts in the auto plastic 
inethml, and. imlt'st* tliere is a very large gap to be filled, in the hetero- 
plastic also, must he broken up iiit») small pieces and placed accuratt ly 
111 the axis of the bone. Any periosteum must be carefully preserve*!. 
Where no ronnerting perioateum w preseot, as was the case in Sir W. 
McKwen's patient, a gnKive must be made between the niuakes for 
flic reception of the grafts. An interesting rase, quoted from the 
(ierniaii Siirgicul Congress Tiiiimctions, I'.KMi,' shows that a brge graft 
may be employed and that living bone is not essential. 

RauKi li, of 8chonebelg. filled a gap 9 cm. long in the xhaft of th«" tibia, the 
mult of the exciaion td a portion of the bone for n myeloid growth, by graftnig • 
iwrtion of tibia of mifHcient length taken from an aniputatwl limb. K»fore this 
wa.x wrunil in its new iNwition by ivory |»«'gH. it wan boiUil to ouHuro Ht< riliHatii)ii. 
Niui nioiitliM latt r tho leg wan anipntaleil for ncurn me of llic growth, and < xnniina- 
tion then nhowetl thai the raftttl {N>rtion had timily united at eaeh end and that it 
was covered by new fM tioHt^-tim. 

(!') T/ic iisf of fhniln'Jii'd Bouc. This is .sometiiin - employed for 
filling cavities in bone, such as are left after removal of a secjuestrum. 
Though occasionally succes.sful the results are usually di.sappointiiig. 
This is owing to the septic condition of the cavities, the foreign sub- 
stance being nsuativ disintegrated and discharged. 

(."5) Thf Iodoform Bonf-JiUitnj of Moestig andMoorhof. This also may 
be used for filling cavities in bt)ne. The material consists of : Finely 
powdered iodoform <!<> parts, spermaceti oil 40 parts, oil of sesan.' 
40 parts. The cavitv must be aseptic and should be thoroughly dried 
preferably bv means' of a hot-air blast. The iodoform wax is melted, 
shaken up, and then poured into the cavity which it completely fills 
to the normal surface of the bone. The soft parts are then brought 
together without drainage and the wound completely closed. The 
chief objection to this method is that mentioned for decalcified bone, 
viz. the difficulty in ensuring the a-sepsis of the cavity. It is stated 
that the best results are obtained when tuberculous cavities are treated 
in this way. 

* Ann. of Surg., vol. xliv, p. 792. 




(Kipt. 'M ami U2) 
Owinj.' t(( its proxi (itv to tho hniwnw as it; lies in the mttsrulii- 
spiral nnM>vtv , -t ni-r • is lialilc to injury in fnii f urrs iilMiiit the niiilill« 
of the shaft,' imUut ' liicerutioii by tlw fructun il I'luis of tht- \m,e or by 
rabMNittently brnmiinR invdwd in the «illu«. In wthrr rai» oppwtion 

Fm. 91. A. IHtoiil. B, Outer heail of trirrps. r. I,i>im Ifuil. II. Inmr 
bead. E, Siipinatiir loiiL'ii.s iinil I'xli-nsiir. < '. Hadialis liiii)(i<ir. I'. 
doni. «, Siii«Tlii iai liriinih of piistiTiiir lin iiiiillix. fc. Aiia^loiiicit ii ii. I.I. 
(.'utanroiiH hniin lir« n( l iiciiniMcx. 2. Iiitfrnislii liiinii ml. :i. Iiilt riial 
« iitiin<-<>ii!< nf iiniw iili. spiriil. 4. Ni i vr <'f Wri^ln ru. .">, I'lwtiTixr limm-ji 
of internal fiitaniM>ii». )i. Kxtcriial iiitiiiii'oiis liniiulirs of luuwiilo-spiral. 
• Accomion. t lnU«rii»l coiwlylf. (<JoUk>e.) 

will ht' recpiirfd. Ott iiHioiiuily tht> nerve is divided by a stab. Mr • 
Lucas - liiiH rt'conlftl two such ciiscs. 

In <m<' <asi . a lad at. If., tlir axillary vi in anil sii|« rior profuiiila arliiy win- 
woundid. a« well a.s the nius. ulo spiral n<TV.'. w liicli was divldiHl. und itH lowt-r [lart 
torn and notthcd. The daniatti d imrt was lut away and tin- omic imiti-d by fHtgut 
Kuturps C'omiiU tc rccovcrv followed, about three immllM after the injury. The 
otlior cas.- wa.s seen two months after the injury. The mM wan five inches from 
the acromion. opf»osite the insertion erf the deltoid. I)ehind and to the outer Hide 
of the humerus. On laying bare the nerve it was found that there wa.s a high 
division into radial and posterior interos.Me<>us, the latter U int! w vered just after it» 
oriRin. The muRCulo-spiral just before its <livi.*ion. and the radial ni its eomuw nee- 
m«it, were involved in dense scar tisnue. They were freed from this, and 1 he ends 
of the poBterior interosseous, after leseeti-n, were iniited by fine catgut. The arm 
^adually improved with threi- months' g. ' misni and a lompiete cure foUowtil. 

> Much interesting inforniation on this .subject is contained in a pa|M r by Dr. < harlfcj 
Scudder and L>r. \ Paul on " Mustmlar .Spiral ParalyaU Complieating Ftactw* ol 
the Humerus." (^iib. of Surg., i«09, vol. 1, p. 1118.) 

» Ch^'t Uoifm BtforU, ToL xlvi. p. 1. 


Relations (Fig. !t2). lit the upper third of the arm the nerve runs 
vertically downwards, behind the brachial artery, to tl' inner side of 
the humerus, resting upon the long head of the triceps, in the middle 
third it passes oblicjuely downwards and outwards, with the superior 
profunda artery, close to the bone in the nuisculo-spiral groove, at first 
between the long and outer, and then between the outer and inner 
heads of tl ■ tricei)s. In the lower third it pierces the external inter- 
nniscular septum and passes to the bend of the elbow in front of the 
external condyle, between the brachialia anticus and the supinator 

Operation. It will most frequently have to be expo.^ed in its middle 
third, as it here lies close to the bone in the groove and is especially 

Flo. 92. A, Deltoid cut and partly turni'd forwards. B, In- 
fraspinatus. t'.Tt ros minor. D, I). Teres Major. K. K. Outer 
head of triceps, part of which has iR'eii removed, (i. Middle 
head, H, Inner head of trieeps. I, I, Sujiinator longus, cut, 
and the upper part rt^Hected. .1. E.xtensor C. radialis longior. 
K, Anconeus. L, t'omiuon origin of extensors. M. Hrachialjs 
anticus. a, Poaterior circumflex, b. Branch of dorsalis 
sraipuUe. c, Superior profunda. I, 2, 2. Branches of circum- 
flex to deltoid. 3. Cutaneous branches of cireuniHex. 4. Branch to T. minor. 
5, Musculo-spiral. B, tl. Branches to outer head of triceps. 7 and 8, External 
cutaneous branches of museulo-spiral. the former supplying outer head of 
triceps, it. Branch to long head of trieeps. I(t, 10, Branches of musculo- 
spiral to brachialisanticus. 11,11. Branches to supinator longus. 12, Branch 
of extensor carpi radialis longior. (tiodke.) 

liable to injury by fractures in this situation. An iiiei.sion. four inches 
in length, should bo made in the axis of the humerus on the posterior 
aspect of the arm. The centre of the incision is opposite the insertion 
of the deltoid. The posterior border of the latter muscle is identified, 
and then on separation of the long and inner heads of the triceps the 
nerve conies into view. For free exposure it is however necessary to 
incise and separate the fibres of the inner head in the vertical direction. 

If required, the nerve may he exposed in its upper third by an incision 
along the internal bicipital ridge opposite the lower extent of the 
posterior fold of the axilla. It will here be found resting oit the latis- 
simuB dorsi behind the brachial artery close to the inner aspect of the 
humerus. In the lower third it may be readily exposed by an oblique 
incision in the interval between the supinator longus and the brachialia 
anticus. The median cephalic vein should be drawn aside and, on 
■epaiatton of the above-mentioned muscles, the nerve comes into view. 



UOATUBE or TBB AmLAST ABTBBT (Figs. 9:)-96) 

Indications. (I) Wound of tlic artcrv.' 

(2) Aneurysm of the luachial \i\}ih tip. 'I'lio following; iiistnictivo 
rase' will rephj perusal. It (I) enfoiros the inipoitanee of exploiiii},' 
at once a wound near a large artery that has bled " profusely " ; (2) it 
proves, if this step be not taken and a traumatic aneurj'sm arise, how 
much the old operation of tyinjr the vessel above and below tlie aneurysm 
and emptvinfi the latter of riot is to be preferred to the llunterian 
method;" and ("5) it is an inter- 
esting instance that <;an};rene. 
which is by no means unknown in 
the lower limb after ligature of the 
external iliac (</.»• ). may also occur 
in the upper extremity with its 
better collateral supply. 

A man, ii-t. .10. acridentally »taMK-<1 
himM-lf in the outer iisiKcl of the ri«lit 
»rm. in its midillc tliird. Profuse 
hiemorrhagc followed. Tlie wound was 
olennned and ilressed aiitise|itieally. and 
the arm was lianda^ed from the liaud 
upwards. The |iatieiit was sent houie. 
hut at uiuhl severe hleediun aiiain set iu. 
This was arrested hy " |>lugt;iiif;. " The 
following nielli lia Tuorrhaile re. urred. 
and was afjaiii arrested li\ pliijl^iiij!. The 
wound jiraduallv healed. and. Ihreeweeks 
later, a eireuinserilH-d trauiniitie aueur- 
vsiu of the brachial arterv devcloiM-d 

lit " the wat of the original wound, hut on a hltiher level. ' The aneurysm ni<<l 
rapidly, soon occupying the whole of the iiuier iin<l anteriorasiH ( I of Ihi u|i|.ei arm, 
caunirig (vdeiim Mxil low* of m-iiKHtion of the hand and lin^c rs. AImiuI fourteen 
days later, prenHure having failf<l, it wuh deeiiled to tie the axdlary arl. rv iii its 
thi'rd part. This cured the aneurytim, but gangrene ' of the llnnnh. togetlx r with 

' In some wiiunils of the arterv. the surnMnidinf parts. . .7. veins iind n( rv< s. may bu 
w. injured, that the vltalitv of Ihe linil) is inipaireil lieyonil what lii;atnre anil nerve suture 
can do, aTi.l the a(lvi>ahility of aniputatinK at the slionlder joint nnist Ih- considered. 

-'/-'<"'■'' lH'.t.->. vol. i. 1"). <.»-2. ,., , . . 

^ It is always invi(Uc«is to criticiw oawa. cs|K'cially those which the writer ha* not 
Bcen and it in "only fiiir to the surgi-on who |«il>lishes this to ipiote his wonls. " The 
only alternative woidd have N-cn to open the am iirysrn. turn out the contonts, and 
attempt to tie htith end- "f the .-vrtery. an oj eration fniiiL'ht with L'reat dauL-er to thi' limb 
and to the patient in his then weakeii. d condition."' 

' In this case the rr|K'atcd blcc-ding had reduced the hiiv of the main vcssid (as in tho 
cane mentioned ftt p. 152) and it« anaatomonm. Ligature of the sxillarjr artery, very 


Kio. !>S. IncisionH for lipilure of the 
first |ii»rt of the axillary artery anil the 
third |>art of tin' sulK-lavian. 


sloughing of the tendons of the foreanger. commenced thirty hours afteni*ldi.. 
Am^Ution erf the thumb at the metacarpo phalangeal joint was required later on. 
and the index finger remained stiff. 

More rarely still : (3) Asa distal operation for aneurysm of the sub- 


(4) In some cases of axillary aneurysm. 

(5) For hemorrhage from malignant disease m the axilla. 1 his last 
is extremely rare, but a good instance, and one showing the difficulties 
which may be present, was published by Sir W. &avory.» Injury to 



Of Me Ol AH M. 

Fio. 04. Anatomy of the parts concerned in ligature of the axiUary artery. 

the axillarv vessels during removal of the breast is dealt with under this 

''^^Ewults ol injuries Irom modern buUets to the axiUary art«y,« trail- 
matie anranram, varieoM aBtonma* vbA. antanpuaal wis. 

These are given by Mr. G. H. Makin« : ' r *u_ 

E^trml primanj hnmorrhnge from the great veMels of the limb« or even of the 
neck proved responsible for a remarkably small projmrtion of the deaths on the 
battlefield. Only one case of rapid death due to bleeding from a limb artery 
was recounted to Mr. Makins. In this a wound of the lirst part of the axillary 
artery proved fatal in the twenty iniiuit.s oe< iipied by the removal of the initient 
to the droxsing station. With ngaid to the treatment of primary ha-morrhage 

probably, further cut off the blood-i upply through one r.f the most important colUteral*. 

▼i«. thc ttuperior profunda (p. 150). 

> if«!<<. '"IkiV. T*™""" vol. Ixix. p. 137. , , , ■„ ^ I, 

« Reference may be made to an interesting cure of a woiiii.l of llii axillary artery oy 

• pistol bultet recorded by Dr. F. W. Murray {Ann- of Snrg.. li»09 vol. 1, p. 448). 

Thefint put of the artery was ligatured and the gktient made an excellent recovery. 
» S«»y<wi SKperie»et$ in SotM JJriat, t80B-ltOO. 


whilf tlic r<iwlino(« with which K|H>ii»iUH<)ns (■•■ssatioii of lucinorilinuc Miiall 
calibn^ woundit was secured w is very inark«<l, the fre(|m ii( v with wliii h Irniiinatie 
anoiirvKms of every variety followed' shows thai the iihiiiiate result is in inany such 
caws hy no means satisfaetory. " Tinier the eircumslani cs it may 1m' said that the 
classieal rule of liflalion at I he point of injury should never he disrejjanled. Af;nini(t 
this, however, ei rtaiii ohjei tions may he at once raised ; thus in many eases Ikjth 
artery and vein nei'd ligature, a coiiHidcnit ion of much imiiortunco in tin* cam> of 
siieh Vessels lis the carotid and femoral artoricH. . . . l)n the whole it «c<>mHck«r that 
the milit«ry awgeon muut be guided by circiiniHtanseH. sinw it may be far better to 
tUk the chances of recurrent hiemorrhaRP or the flevel<nmieiit of an anciir>-8m or a 
varix, than thoBO «rf gangrene of a limh. or softening of the hrain. As a ^'eIleral rule, 
therefore, on the fieM or in a lield-hospital. primary lifiature of the ^reat vessel is 
fjest reserved for those cases only in which ha-morrhape jM rsists. while in H'osc in 
which spontaneous cessation has oceurreil. or in whii li hlei-dins is n>adily controlled 
by pressure, rest and an cxpietant attitude are to he preferred." , , „ 

Srrimdnrt/ htemiirrhiige in simple woumls hy small ralilire hullc^ts was decidedly 
rare: in co'mimund fractures. cs|M-cially of ihv "explosive" kinil. il was not iin- 
eomniou. Lesions of vessels short of |K'rforation. hut eausiiifj devitalization of the 
walls. iK-rforation hy a sharp spicule of Ikjuc. and. in the larne majority, sejisis and 
suppuration were the chief eaum's. The treatment to lie adopted de|M'nds on the 
nature of the case. When the wouikI is aseptic and hk-cding. the result of se|iniu- 
tion of sloughs (this was found to be very tardy in aseptic wounds), local ligature is 
the proper treatment. In septic cases, on the other hand, it is usually far iR-tter to 
amputate, unless the general state of the patient and the lixal eonilitions are 
esiKcially favourable. When neither amputation nor Iroal ligature is practicable, 
proximal ligature may K- of use. Thus one case is given in which ligature of 
the common caroti(l was successful for ha'rnorrhagc from an arterial hiematoma in 
connection with the internal maxillary artery. 

Trninnntic aneuri/xms. The exiH-rience of th<' cainpaigTi fully hears out that of 
the iwist as to the steady increase of the nmnher of aiieiuysnis from (.'iinsliot wounds 
in direct ratio to diminution in the size of the projeetil<>s employed. Kvery variety 
was met with, and most frcciuently of all. is rhaps. aneurysmal varices and varicose? 
aneurysms. The following are itislanecs of traumatic ai.curysms of this rci;ion. 

False Iraumntir aniiiryiims or aneurj-smal ha'iuatoma of the axillary artery. 
Kntrance wound in jMwterior fold of axilla, exit one anti a half inches U-low the 
junction of the anterior fold with the arm. The man rode four miles after In-ing 
hit. but the horse then fell and rolled over him twice. The wound healed, hut the 
whde upper arm was swollen and discoloured, while an indurated mass exti nclcd 
along the vessels into the axilla. This was not obviously distcnsile. and pulsalam 
was veiy slight. The pulses 1k-1ow were absent. A tluctuating swelling was present 
along the anterior border of the deltoid. Tactile anaslliesia existed in tlie area of 
the median ncr\'e. On the thirty-Hrst <lay considerable enlargement was noticed 
This, together with continued rise of tem|(craturc. aroused suspicion of suiipiiia- 
tion, and an exjiloratory punctuie was made by Major Longhead. K.A.M.C. after 
consultation with Prof.' Chicne. Clot escais'd. followid by profuse haemorrhage. 
The incision was enlarged, while compression of the third part of the subclavian was 
maintained, and an oval wound half an inch long was found in the axillary artery. 
Ligatures were api)lied above and Im'Iow the opening lietwccn the converging heads 
of the median nerve. All the swelling disapi)carcd with the healing of the wound, 
but the diminishe<l median tactile sensation jiersistcd. A somewhat similar case, 
but one of true traumatic aneurysm, treatctl by double ligature of third part of the 
axillary artery, came under Mr. Jacobson's can? in the spring of l!Mi2. at (!uys 
Hospital. The patient had been shot through the inner and upis r part of the 
|iectoral region, the wound of exit Iwing in the jiosterior fold. He received the 
wound in one of the night attacks on our camjis. and his assailant was so close- 
that he kiUcd him by a snapshot with his rifle resting on his thigh. Itoth wounds 
healed by first intention, and he was admitted for diminished tactile lenBatHm 
over the area of the musculo-spiral. 

The radial pulse was normal, and there was nothing to call attention to the 
existence of an aneurism. X bniit was not. however, listened for. The niiisculo- 
spiral nerve, which alone apix-ared damaged, was explored by an incision along 
the axillary vrswls, with p.nrtial division of the great peetor No damage could 
Ik? found in the course of the nerve, but, as it was traced upwards, a small oj«>W 
sac of a traumatic aneurysm was found between the two bead* of the median 
nme. Ugotauw wwe puced above Mid bdow, the aneurysm opn»d, and khiw 


«Jd clot tamed out. Owing to the iiitiinnte assooiiition of the nerve it «cemed 
wiser not to try nn<l remove tlie nncurvsm. It wuh ho|)e(l that nny pressure which 
the iineiirAsin might lie inal<in); on the nerve uimid gradually diminish W'»h the 
shrinking of the o|H'neil sae. This, however, was not realized. When the patient 
left the liospltal there was no evidence of recovery of the diminished tactile sensation 
over the musculo-spirul urea. A very similar case is given by Mr. Makina.' The 
MaiMcr bullet entered two and a half inches below toe acromial end of the right 
clavicle, and emerged over the ninth rib in the posterior axillary line. 

Three weeks Inter the woupd being healed, a large pulsating haematoma was 
note<l in the axilla. Signs of injury to the museido-spiral were also observed. The 
swelling altering little. Major Burton. R.A.M.C., cut down ujxjn it through the 
IK'etorals a fortnight later. The nneurj-sm was of the third part of the axillary, and 
II ligature was api)lied nt the lower margin of the peftoralis minor. The wound 
healed by primary union, and when the man left for England • month hter, the 
niuseulo-spiri'l jiaralysis was improving. 

AHtiirii-imal Vnrir and Varironi Aiinirj/sm. The frequency with which these 
oieuried and the larger pn)|iortion of the latter has already hnni alluded to. With 
regard to treatment Mr. Makins (p. 14.5) warns us that " while modem surgery^ has 
lightened the difhculties under which our predecessors approached these operations, 
Kone the less the experience of this campaign folly supptnrta the objection to indis- 
criminate and ill-timed surgical interference, as accidents have followed both direct 
local and proximal ligature. The following are Mr. Makins's chief conclusions : ( I ) I n 
anenrysmal varix there should be no interference in tlii' early stage, in the abw-nee of 
symptoms. " In many cases an expectant attitude may lead to the conviction that 
no interference is necessary. es|K>eially in certain liituntions wlierc the danger of 
gangrene has been fully deiiionstrated.' In eonnection with this subject Mr. Makins 
relates two cases in which an aneur\sinal varix, in one patient of the femoral vessels, 
in the other of thi axillarv. had existed for years, and hod not interfered with the 
patient's work. In the second case, after twenty years' existence of the varix. the 
patient ns a combatant in South Africa was subjected to very hard manual work. 
Tiiis brought about increase in size, cervico-brachial neuralgia, &c., and in con- 
sequence, the man was invalided. (2) The arteries of the ui)per extremitjr are the 
most suitable for operation, and the axillary may. perhaps, be the vessel in which 
interference is most likely to be useful. The vessels of the arm and forearm may in 
almost all cases be interfered with, but in many instances the absence of any serious 
symptoms renders operation unnecessary. (U) The operation most in favour 
consists in ligature of the artery aV)ove and 1k-Iow the varix. the vein remaining un- 
toi;ehed. . . . Failure is due "to the jiresence of collateral branches, which are 
not easy of detection. Even when the vessels He ex|>osed. the even distribution 
of the tiirill renders determination of the exact jioint of communication difficult, and 
the diftieulty is augmeiited by the t mporary arrest of the thrill following the applica 
tioM of a proximal ligature. ... If the vein cannot l>e spared, excision of a limited 
part of both vessels may be preferable, es|M'clally in those of the up|)er extremity."' 
Single ligature or proximal ligature is useless in aneurysmal varix. (4) "Given 
suitable surroundings and certain diagnosis, the ideal tn-atment of this condition, 
as of the next, is preventive — i.e. primary ligature of the wounded artery. Many 
difiieulties, however, lie in the way of this beyond mere unsatisfactory surroundings 
It suffices to mention the two chief : uncertainty as to the vessel wounded, and the 
necessity of always ligaturing the vein as well as the artery in a limb often dis- 
sected \ip by extravosated blood, to show that this will never be resorted to as a 
routine treatment." 

(ii) Arliri<i-vin<mi>anrur;iKm. Many of the alM)ve remarks tind equal application 
here, but in the |)ri'seiice of an aneurysmal sai' iion interveiilion is rarely possible 
or advisable. . .. In the early stages the ])ro|K'r treatment in any case consists in as 
comiilete a position of rest as ]Hjssible. and atfording local supjKjrt to a limb by a 
splint, preferably a removable jdaster of Paris case. Should no further extension, or 
what is more likely, should contraction and diminution occur, it will Ix- well to 
continue this treatment for some weeks at least. When the aneurj'sm has reached 
a quiescent stage, the question of further treatment arises, and whether this should 
consist in local interference or proximal ligature. ... In the case oA arterio-venous 
aneurysms in the Urnbs the possibilities erf treatment are enlarged, and here the 
ahemativeB of (a) local interference with the sao and direct ligatoro «^ tiw w ound ed 
point ; (6) simide ligature above and bek>w the lao ; (e) {MNnimal ligature (HuntmiMi 
opeiation) {wesent themselves, 

' Lot, §ufra eil., p. ISi. 



Mr. MttkinsH opinion is Ntronsly "to the <IItit (Imt none of these o|M-r«tit)n» 
Khould 1h' undcrtiikcn before a iK-riotl of from two lo thnt- luontiM after llie injurj-. 
unless there in evidence of progrciMiive enUrgcHH-nt. ■ In every eaw whu-h c»nie 
under ray own observation. |)rogreii»ive eontmetion ami eonHolidalion took plaee 
up to a certain point under the inttueme of n-Ht. When this process has iHronie 
stationary, and the Rurrounding tiiutueH have ngiiiiiid »« a gnat i xti iit tlu ir iioiiiial 
coiiditkm, the opemtkmii are far ea«ier. and bi \ .md this nH>re likely to be followed 
by snccem." 

Writing five years later in a paper, in v, liich a later hi.story "f -several 
of his cases of arterio- venous aneurysm are f;iven. Mr. Makins. speakin<; 
of operative treatment generally says : .V li<;atiire i)laced as near as 
possible above the aneurysmal sac bias been shown t«) be safe, to ailord 
a reasonable prospect of cure, and not to ])ieju(lice a further operation, 
shouhl this become neces.sary." Anil with n.ore i-.special reference to 
the arteries of the upper extremity, tiie same authority writes: "My 
personal exnerience of published cases shows that a proximal lijiature 
may with safety and a fjood chance of success be applied to the veasels 
above the elbow, and for wounds at the elliow itself, this jinjcedure is 
to be generally preferred. In the midarni a local oiieratioii is siinple. 
and in the forearm the same may be said. In either of the latter situa- 
tions a local is to be preferred to a proximal operation, as more nearly 
approaching the ideal and necessitating no obvitms risks." 


Collateral circulation (Fig. Mtl). {a) If the artery be tied in its 
first part, and the ligature be placed above the acromio-thoracic. the 
vessete concerned will be the same as those which carry on the blood- 
supply after ligature of the third part of the subclavian iq.v.). 

(b) If the artery be tied in its third part, and the ligature be placed 
below the circumflex arteries, the anastomosing vessel will be the .sam< 
as after ligature of the brachial above the superior piofunda (scr p. \'.\) 

(c) If the artery be tied in its third part, and the ligature be placed 
between the subscapnlar and the circumflex arteries, the chief vessels 
concerned are : 

Above Below 

The supra-scapular ^.j^j^ ^.j,^ posterior circumflex. 

The acromio thoracic '■ 

(d) If in tying the thiid part of the artery the ligature be placed 
above the subscajjiilar, the anastomoses are more numerous, viz. in 
addition to those junt given : 

Above Belotv 

The supra-scapulai ^^y^ ^he subscapular. 

The posterior scap ilar 

Operations. Ligature of the first and the third parts of the artery 
will be first described, and then the old operation. 

(1) Ligature of the flrit part (Figs. !t:5 and !I4). This operation is 
very rarely performed on the living stil)ject. Owing to the depth of 
the vessel here, its most important and intinwte surroundings, and the 
risk ' secondary hsemorrhage from the vessels which He so close to 
the knot, ligature of the third j)art of tin sid)clavian is preferred if 
ligature be required for axillary aneurysm. On the dead subject the 


student shoulil always take the opportunity of tying the first part of 
the axillary, as it is an excellent test of anatoiniral knowledge and skill. 

Line. From the centre uf the clavicle (with the arm drawn from 
the side) to the inner margin of the coracu-brachialis. 

Guide. The above line, the coracoid process, and the inner margin 
of the coraco-brachialis. 


In Frotit 

Skill ; fascia' ; fibres of platysnia. Supra- 
clavicular nerve. 
Pectoralis major with the ext«mal anterior 

thoracic nerve. 
( 'osto-coracoid membrane. 
Cephalic vein. 
Acromio-thoracic vessels. 
Ovtaide Inside 
Outer and inner cords of Axillary artery Axilhry vein, 
brachial plexus. first part. 


First digitation of serratus niagnus. 
First intercostal space and muscle. 
Posterior thoracic nerve. 
Operation. 'Die vessel may be secured in the following ways : 

A. By a curved incision below the clavicle. This gives the necessary 
room, but has the disadvantage of dividing the pectoralis major and 
its large muscular nerve. 

B. By an incision in the interval bettreen the pectoralis major and 
dtltoid. This methoil scarcely gives room, especially if the parts are 
displaced by effused blood, &c., and it is well to supplement the incision 
in the interval by one partly detaching the pectoralis from the clavicle. 
While this plan involves less ha-morrhage from the pectoralis major, 
care must be taken to avoid the cephalic vein and acromio-thoracic 
branches which lie in this interval. This end is best secured, whichever 
method be adopted, by going down on the artery as close to the 
clavicle as possible, the sheath of the subclavian being opened, and 
some of its fibres detached, if needful. 

('. By an incisioH in the tine nj the artery, ri'j. one three and a halj 
to four inches long, starting from just outside the centre of the clavicle and 
passing doicnwards and outwards. This has the disadvantage of cutting 
the muscular branches to the pectoralis major, and gives less space 
than the first two. 

A. The limb being at first abducted, the surgeon, standing between 
it and the body, which is brought to the edge of the table, makes a 
curved incision, with its convexity downwards and about half an inch 
from the clavicle, reaching from just outside the sterno-clavicular joint 
to the coracoid process, the knife being used lightly at the outer end 
of the incision, so as to avoid wounding the cephalic vein and branches 
of the acromic-thoracic vessels. The clavicular origin of the pectoralis 
major is then divided in the whole extent of the wound, and any muscular 
branches whicii require it tied or twisted at once. 'J'he arm should 
now be brought down to the side to relax the parts. The cellular tissue 
beneath the muscle being next explored with the tip of the finger and 


director, thi' iippi'r l)i>rilt'r of tJic |n'ctiirali.s iniiior is (li'liiii'd. iind this 
iiui.sclt' drawn tlownwiirds. TIk' costo-coriK oid mciid)raii(' must next 
be most carofully divid ,1 in the vtMtical direction, the a< romio-tlmrucic 
vessels und the cephalic vein he'infi mmt scrupulMUsly avoided. Tlie 
latter forms a usenil jjiiide to the position of the axillurv vein. The 
wound all this time must lie kept dry. and, if needful, u larp- larynfjeal 
mirror or an electric head lamp may be usefully employed in throwin*; 
light into the bottom of the deep wound. The puktation of the artery 





^cuT eoae. of 



Flfi. 03. l-iiiutiirf c)f till' tirst part ot the rii;ht nxillary artery. 

beinjj felt for in the livinfi. and its flattened cord-like feel nmde out in the 
dead subject, the sheath is e.xpo.sed. and the ves.sel itself carefully cleaned 
and .se])aiated from the vein, which lies behiw ami in front, and from 
the brachial cords, which are above the artery. The needle should be 
passed from below so as to avoid the vein. 

B. By an incision made bet\reen the pcctoralis major and the 
deltoid. The limb and the surgeon being in the same position as in 
the operation just i;iven. an incision is made obliquely downwards and 
outwards between the above nuiscles. commenciiif; at the clavicle 
opposite to the coracoid ])rocess. Care beinji taken to avoid the cephalic 
vein and branches of the acromio-thoracic vessels, the mu.scles are 
separated and. to fjain more room, a transverse incision is made runnin<; 
inwards along the lower border of the clavicle, and detaching as much 
as is required of the clavicular origin of the pectocalis major. This 
flap can be turned inwards and downwards without any interference 
with the nerve-supply of the nuiscle. and. owing to its division high 
up, less hicmorrhage is met with by this method. The deltoid being 
strongly drawn outwards witli a retractor, the upper border of the 
pectoralis minor is defined, and the operation completed as in the 
account already given, the parfas being relaxed at this stage by abduction 
of the arm. 




(I) Ligatnre of the third part of the axillary artery (Fig. Ofi). Linr. 
From the ceiitn' of tho rlavicle. with tlic arm in tlio ahdiictcd potiitioii, 
to tlio innrr mar<!in of the ooraco-brafhialis. 

fliiidr. (I) Tho above line. (2) A line drawn from the junction 
of the middle and anterior thirds of the axilla, along the inner border 
of the coraco-brachialia. 

Fio. 96. Ugiktura of third part of the left uillaiy artery. 


In Front 

Skin ; fascia;. 

Pectoralis major (at first). 


•Musculo-cutaneoiis. median. Axillary 

Inner border of ' artery 
coraco-brachialis. third part 


Subacapularis. Latissimus dorsi. 

Circumflex nerve. 


Internal cutaneous ; ulnar. 
Axillary vein or venao 

Teres major. 


somewhat that for ligature 
As with the brachial, so with 

Operation (Fig. 96). This resembles 
of the brachial in the middle of the arm. 
the axillary here ; though the vessel is comparatively superficial, it is 
not an easy one to hit off at once, owing to the numerous surrounding 

nerves. wTiich may resemble the artery closely, especially if blood- 
stained. The axilla having been shaved and thoroughly cleansed, 


the arm IxMnj; fxtcnd.-d from tlu> suit- am\ rotated slifihtly outwards 
(not too forcibly, ua this will alter the relatioii.s), the tsurfjeon. sittiiifj 
between the limb and the trauk, nmkes an iiuisioii three niches on^; 
at the junction of the anterior and middle thirds of the space alonj; 
the inner border of the coraco-brachislia (Fig. IKi). The incision niuy 
he hefiuii above or below, as is moat convenient. Skin uiid fascia; being 
divided, and the iM)int of a director used more deeply, the coraco- 
brachialis is identiKed. and the a.xillary vein and the median nerve are 
.listingiiished from the artery, the former drawn inwanis, and the latter, 
tojiether with thecoraco-brachiaii)!. outwards.' The artery is then clearly 
defined, the sheath opened, and the needle passed from within outwan s. 
the neighbourhood of anv large branch, such as the or t he 
circiimHe.x, being avoided, and the needle being kept very close t»i the 
artery. Instead of one a.xillary vein, two venae comites and the basihc 
as well iiiav be pre& 'lit. 

(.{) "Old"' operation ol ligature ol the axillary artery ( " OpetaMon 
ol Antyllus ") for lome cases ol axillary aneurysm and injured axillary 
artery. This method may be called for (I) in li.'' following cases of 
sjMjntaneous aneurysm (a) when pressure is considered iindesirabl'' 
or has failed. (/*) when, owing to displacement of the clavicle, ligature 
of the subclavian is not practicable; (c) when the condition c.f the 
coverings of the aneurvsm is such that this step, even if earned out, 
will not avert suppuration, sloughing, &c. Professor 8yme« quotes 
the following case, in which this method was employed. 

" I made an incixion along the out«r edge <Jf the stemo-maHt.iid (hroiijjh tlic 
platysnm niyoides and fascia of the neck, so as to allow a finger to Ik- pu-shi tl < own 
to the situation where the subclavian lies ui^on the tint ril>. 1 oik..u <I • 
tumour, where a tremendous gush of blood showed that the arte n- was not elU . I i.a 1 y 
comnnHHcd ; but while I iJuggc<l the ajH-rturc with my hand. Mr. I.i«t.r, who 
uKHlsK-d iiic, l)y a slight movement of liis linger, whieh had Ix-eii tliriist deeply under 
the upper edge of the tumour and through the elots eontamed in it. at length kiu - 
0(r<le<l in getting command of the vessel. I then laid tlie eavity freely open, and 
Willi both liaiid.s seooiH-d out nearly seven jMiunds of coagulated 1)1o(hI. the axillarv 
artery apiK^ared to have been torn aeross.und as the lower onliee still bled profusely, 
1 tied it in the first instance, next cut through the lesser jn'ttoral niu.scle closo^up to t^ 
clavicle, and, holding the uj.pcr end of the vessel U>tween my hnger andthumb. 
passed an aneurvsm needle so as to apply a ligature about half an inch above the 
orilic( . The extreme elevation of the cUvicle, whfch rendered the artery so m- 
accessil.le from above, of course facilitated this procedure from below. Every- 
thing went on favourably afterwards." 

(2) In many cases of traumatic aneurysm and injury of the artery. 

Lieutenant Colonel Sylvester:' collected five eases of injury to the axillary 
artery followed by traumatic aneurysm, treated in this way, all of which recovered. 
The following is a good example. Wounded at Elandsbagte. Seen at VVynberg 
fourteen days later. Anterior-ixjsterior wound (Mauser) at upper end of humerus, 
Imne not damaged ; no severe hajmorrhage at time of wound. Diffuse aneurysm, 
occupying axilUwry space, suddenly formed <»i twelfth day, and anterior wound 
began to ooze blood. An incision was made over line of vessel, large quanUty eS 

' FaraLeuf (loc. supra ext., p. 44) gives the following directions for makmg sure of tho 
artery. .Make an incision running just behind tho anterior wall of tlio axilla. luentiJy 
the cora( o- brachialis by oin nins! its sheath. Draw It outwards, and with tho finger of tho 
left hand sunk in the woiuul. depress tho whole bundle of vessels and norvcs. 1 ho Hist 
cord which e«cn5»w upward^, wtien the fineer is withdrawn a little, is free, perforating no 
muscles : this tho median. Isolate it and have it drawn outwards wiili tlu- coraco- 
brachialis. The second large cord, uncovered by withdrawing the first, is th« artery. 

^ Obsi rvdtionn in Clin. Surg., i>. lis. 

» Jtepl. on Surg. Cases in the South AJrieaA War. ^ 


clot turned out. ami wniiiicl found in third |>art nf axilliirv nrtcn'. Tho iiiitrr MMts 
of tlio VfKwl liad liti n ^ra/iil fur tlir x\uiii- of an ini li. and the arliTV liad gircn 
wny in th«' middk- of tliiit. Vciwi'i li|{ulurrd ubovt- und U-low, an<i diviiied betwmi. 
Uiuntmiiptcd recovtiy. 

Sir J. I'aircf and Mr. CiillciHlcr' nmdi' a H-"*!!"!"''' imini"". ciittiiifj! 
|»aralli l witli tli»' lowi-r iiiarpii of the iM'ctoralis inajnr. niul a mh-oikI. 
at ii<:lit aM;.'l(-s to the first, straight up through the whole width of tlie 

pfctoralis major. 

.Mt'iitioii may also Im- made here of that moMt im|M)rtant accident 
which has happened to Mt many surgeons, viz. rnHsM of th» uUlatjr 
uttnr ^rUH» AnesatiOM of th« ihonUar m b^nc ndtiMd. 

K>''rtc. of lii'ilin,- is of opinion that in many vhhiv tlir injury to the artery in 

CAUw-dat tlii-lii f tlic airidi'nt. hut ha'niorrhav'i' iIih's not < oinf on till after nihic- 

tionw brought ultout, AH thttvewH-l In foniiircNwd hy the head of tlie l)on<'. As toilie 
exact cauKC of the injury to the ve«Mci when it tiilctii|ilHeeatthe time of the reiluttion. 
it is probable that wmie condititm exititM to aecount for it. e.g. atheroniA ; odheition til 
the artery to the hi>nd of the bone ; too grent or mimpplii^ force in niiuction, vi*. 
use of the Ikk>i in elevation ; jiTojeefion of a fragment or a ii|»icuk» of bone. It l» 
usually the axillary artery, or one of its liranehes. whieh giveH way; much more 
rarely (f<nir out of forty four eases, the axillary vein. 

Tito followiiif; case, under tlif caro of Dr. X. Raw. of Liverpool.'' 
teaches a point which may he most valuahle in the treatment of these 
rare hut very grave cases, viz. putting a temporary ligature round the 
a.\iilary artery until it is certain whether both this and the vein have 
given way. 

The patient was age<l 4,"», aml^tive we<>ks after a disloeatioii of the humerus had 
been reduced, a surgeon hod manipulatetl the urni with hix heel in the axilla. The 
arm began to awell the same night. There was slight itulsation in lioth radial and 
ulnar arteries. As the accumulation of Nyniptomtt hatl Utii gradual, ruptun* of the 
axillary vein was diagnoxed. Thi- swelling increawfl. and burst with seriouH hiss 
of l)l(M)d. .An incision was made from the clavicle to the anterior fold of the axilla. 
dividiiiK the jwctoral muscles. The axillary vessels were lipitured under the 
clavicle, the a;'tery with a temporary linatnie. The incision was then prolonf;ed 
through to the axilla, down the inner side of thf arm to the elliow. and several |M)unds 
of clot turned out. Tli<' axillary vi^ii; was found torn completely across. an<l was 
tie<l at lM)tli ends ; arterial Mond was seen to !«■ llow iiid. and the siihscapular artery 
wn.s foinid cut across ahont one iruli from the main trunk, and tic<l. The tcmixirarv 
ligature was then removed from the first part of the axillary artery, and followed 
hy redness and warmth in the limh, liul no pulsation in the radial artery. The 
IHiticnt made an excellent recovery, and. six months later, had a fairly useful limb. 

Treatment should be on the lines indicated above, though in some 
cases, e.sp('(iaily in elderly patients, disarticulation at the shoulder 
joint may be called for. 


Indicattont. (1) Compound comminuted fructunts, e.g. railway and 
m.achinory accidents. 

C2) (iiiimhol injuries. .Vtiiputation here is divided by Dr. Otis ' into 
(!) primary, or before the third day ; (2) intcmiediatt'. or ca.scs in which 
tlie operation was performed between the third and the thirtieth days; 
and (.i) secondary, in which the operation was performed later than the 
thirtieth day. 

' St, Jiartholomew's lloxp. hi p <rl--- vol. ii. 
» Arrh./.ldiH.rkir., M. xxvii. Heft 3. 

3 Liverpmd Mri. Chir.Jourtt.. July 1899, p. 328. 

4 Jf erf. and Surg. Hial. of the War of the XebtUion, pt. ii, p. 613. 


(1) I'riiimrii. The iiidii'iiliiiii!* for iirii|nitiitii>n mo nuihi nftiTlliciiijiirvanTliiilly: 
(d) a liriil) toiii (ilf partially. Iiiil Iini liit(li to aiiiiiit of any ol Iht aiiipiitatioii ; 
(fc) Scvi'li' ('oiiiiiiiliiiti'il fiac tiirc' of tln' u|i|><T i inl of tlu' liiinirriiM. with rxtciiKivp 
injury 1» the vfuwU ami m rvi M ; (c) Sui li afrarliirc> \\^\^\^ up. with wvi-rr ii|»lintrriim 
exti'tiililiKilowit lii'low the ituuTtioiis of the pi'rtorali.i major ttttd thv latiiwiliHlH donti.' 

(i) tntirinrdiate. 'i'hf mortality ixTf wum lu'urlyiiuublv tluit of the priiimr)-. Tiiia 
M-cma to have been bioHght about largely bv the fact that the opemtkm waa now 
f^riatmeA thiough aoft pi^t*. the M>at. at this tinm. ol unheaithy inflammation, 
and thiM pRme to lead to wt-omiiiry h»>inorrhaf{i>. pytrmia. iloughiiw. Ac. 

(3) Stcotuhrjf, The cuiiw-m fur thiH ili-fcm-d o|H>rotion wi>ro ciiii>ny ha-morrha||p, 
Kiingrene. prof IMC (uppuration. hopttcaa diofaim (A the huntenw, iwmt>timni with 
i'umecntive implicatian of the joint, chfonio oatco-myelitis. or neoroaia of the entiiv 

(3) New iiriiirthn. If tln-so involve tho .s('ii|uila <ir its pioccHsrH \ \\<- 
upper extrcinity slioiild In' rciiioviMl by the iiu-tluM! of iiitiTHcapiilo- 
thuracic aniputittioii (m-c pp. I'.U 'I'M). The (question of the |MHwibility 
cif saviiif( the limb and rt'iiioviit); the growth by excUon of the beiul of 
th« liumcrus is coiisidennl at p. 214. 

(t) Disease of the shoulder- joint unsuited for, or persistinft after 
failure of. e.xcisioii. 

(•")) For osteo- myelitis and ix-crosis of liunierus resisting other treatment 
or eomplicated with early blooil-poisoniiis;. 

For rapidly spreading gangrene or gangrenous cellulitis with 
threatening septica'inia. 

(7) For removal of the upper extremity when painful, anlematoua, 
and heavy owing to pressure on the axillary veins and brachhial plexus 
by recurrent carcinoma. Ifcre removal of the upju-r extremity l>y 
M. Paul Berger s method (sec p. 'I'.W) is to he preferred. For the advis- 
ubility of such operations .sec " Retnoval of the Breast." 

(8) Amputation at the shoulder- joint may be called for in the following 
cases of aneurysm : 

A. /» mme easts of gubdavian aneurysm where other means have failed . aic 
impracticable ; where the nneurj-nm in rapidly increasiiig ; where the pain is con- 
stant and ngoiuHing ; and where tlie limb is threatening to become gangn;nouH. 
While the principle of thi.i operation apix-arti to be physiologically Hound. i.r. to 
enable distal ligature to \se |)eiiformed on the face of the stump, and that, by removal 
of the limb, the amount of blood jiaiwing through the aneurysm may be diminished — 
the roHultH hitherto have not been very siii'Cfsxful. 

Thus, in Prof. Spence'» case- a "man, aged X'J, with a sulMrlavian aiieurysiii. 
prolwbly encroaching on the .scconil, if not the first, jiart of the artery, with ex- 
cruciating pain and thrcat'iiing gangrene, amputation at the sliouldcr-joint was 
followed by diminution in tlic pulsation ' size of the sac, but with little formation 
of coagula. Death took place for ' 'terwards, probably from extension 

of the aneurysm to the iimomiuate In this case the ojieration, though 

it had but little ctfcct in consoliila ... • sac, undoubtedly prolonged life, as 
gangrene was threatening, and the second part of the artery was almost certainly 
affected, thus rendering the case a most unfavourable one. 

B. With the same objects in view, amputation at the shoiilder-joint may be 
required in some cases of axillary aneurysm complicated with e; i. ' *ion of the sac 
upwaids. much elevation of the shotilder, conditions which may u .;iier compression 
or ligature of the subclavian imjKJssible, removal of the limb Ix-ing additionally 
called for if agonising [Miin or threatening gangrene be present. 

Prof. Syme ^ lirieHy alludes to two such successful cases, in one of which gangrcr.e 
was threatening : " In a case of axillary aneurysm in a gentleman of aliout '■>'! yeais 
of age. wh<'ri' ligature was prevented iiy intense intlammution of the arm, rapidly 

' In some of tlicsc flic adoption of the Fumeaux Jordan method (p, 191) might lead 
to diminished loss of blond. 

^ Med. ( hir. TrnitK.. vol. lii., p. 306. 
3 /W., vol. xUii, p. 130. 



riiiiiiiiiu on til ({iiiitrri iir. I |h ifmiiii d aiii|>iitatiiin at tin- nlmulili r julnt. i iillinx 
tliri>ii|2li till' ^lllll((l>y Kiili N lit till' iiiii'iiryN]!) anil tyniK tlif arli rv wlii rr It l.iy uitliiii 
the nnf." 

('. /« "iitiii rii'i K iif iitfiiimiil iixillnrii iinuirifm I lii<'alriiiii(( xii|i|iiiratioii. Sir •). K. 
KrichM>n ' |Niiiiii'tl out that i\w iiuintkm ul tbiit uin|iutMlioii nmy ariiH'. Ak iIh' iiIiI 
ofH-ratkm of <>|M-niiiK tin- mv, turniim out the ckiiit, nmi wt'iiriiiK iIh- vtfM'l hIhivi' 
uimI bt'luw iit imiiuHiIbk'. owing to tbi- fact that the rutttM dl tb<* vrwl. nam williwii. 
will not liokl n liRiitim*. two couriic only arc o|icn to tiw mirip-on— vix. lifmtnrr of 
IIm> tliinl ixiit of the Hiilivlaviafl, or am|>utation at tlH- Khouldcr- joint. Wliilr tin' 
foniiiT ni.iy Ik' fiillii\v<'<l when th<* nn«>lir>-Mm '\* iniNk-ratt* in Hixc nnil ulii ii tlini' in 
nil rviilriicr of t liriatiiiini.' iraiiKrriir. ain|iiit:itioii niiixt Ik- rciortnl to wlirii Irns 
faMiMtalilr rimilitions air | n m iit. 

If h i iiiiiii'liaui' orriir froiii an irillaiiiril axillary aiiriirvsni uliirli lia- ni|itnrril 
alli r till- j<iil" la\ ian lian Ihtu aliraily tiril. tlir >aiiii' writer, of tin twiiniur-is 
ii|K'n vi/,. I'llln r to i>|ii'n llir kic anil try anil iiirlnilr tlir lilii ilini; ^|Hit Ih lui i ii 
two li|(atiirrN. or to ani|iiitati' at tlir Klnuililrr Joint Ntriinitly ailvisi s llir lalii r. 

li. In tlif worils of Sir .1. K. Krii lism.- " llii-n- ih aiuillirr furin of axillary 
an<'ur>-itm that n iinirrx iniiuriliatr ain|iiitation at tht> Hhoubk'r- joint, whrtlH-r tlu> 
Nnlirtavian arlrry lia\r |irrvioiisly Imth liKatiirni ot not ; it in the raw of (lilTuHf 
aiii'urysni of tlir ariM|iit. witli tliri-atrni'il or ai'tiial gangnJir of tin- liinli. 

Difltrtnt metbodi. Uf ooine thirty-six metbods which buvu Immmi 
dm-ribed. most will be found to differ in Home unimpirtant detail. 
Five uloiip will be jtiven ht-ri' ; they will be found iiiii|ily siiflicifiit. if 
iiKNlitiod when nei'tifiil. fur all citsfs ; and of tln'.sc five, Spt'iicc's, for 
the reasons >.'ivfn below, is the best, and the one with which all opeiatois 
Mhoidd lie faiiiiliar. The (■iiiiinistances tmder which this operation is 
|M'rforined do not admit of any one delinite method being followed. 
Thns, after a railway accident or gunshot injury, the soft parts will Im? 
destroyed on at least one surface. In amputating for malignant disease, 
skin flaps must be made use of, tranMfi.\ion being usually inadinissilile. 
as the muscles shoidd be cut as short an»l as close iis possible to their 
iipl)er atfachtneiits. to iitiiiiinise the risk of e.\tetision and recnrieiin'. 
Insteail of renieinberiiif; the leii<:th and size of (iinVrently named Hajts. 
the snip-on will have to be familiar with the anatomy of the ))art8, 
the position of tlie vessels, and the best means of meeting hu'inorrhage. 

The joint is so wfll covered that sufficient flaps* can nearly always 
be provided, while the bliNid-supply is so abundant that slou<;liin>.' ver\- 
rarely occurs, and even if it does, the tissues of the chest will come 
forward siilliciently to close the wound. While the cavity of the a.xilla 
favours c.\it of (li.scharf;es l>;'low. the abundance of cellular tissue o|)ened 
up favours ilitViise inflammation and calls for ade<juate draiiiafie.* 

The followini; methods will be described here : in the first two. skin 
flaps aie made ; in the others (save in the Fumeaux-Jordan method), 
transfixl..M is made use of, in part at least. In all cases of doubt, 
the conditions of the bone and, if needful, that of the vessels and 
nerves, should be first cleared up by a free incision as if for excision 
(Fig.s. lOit and 110, p. 21-")). 

(1) By lateral skin flaps. The oval or en raqueUe method. 

(2) Spence's method. 

(3) Superior and inferior flaps. 

• Snrg., vol. ii, p. 217. a ior. .^l,|Jr(l cit.. p. 218. 

' In mime cases of gnnshot injury it is nccriMkry to |<ft Ihv iliirf Itnp from tlie 
axillary n>>,'ion. and to bring this up and unite it to the cut margin of the nkin over the 


I rinaily the tcndi iiiy of tilt- >kin tii ri-tract when tai8 has been mnch stretched, a* 
uviT a iargf gruwtli, .slioiild be renielulH'red. 


1 1 1 Sii|»"iiMr III ilclii(iil ll,!)!-! 
(."»( Aiitcriur luul |M».stcrii>r llapH. 
(«M Purn<-iiiix>Jnnian nictlHHl. 

Wliil)' the most ni|>iil iiiftliiNiri nn* tlntm- of itu|N'ri<>r unti iiiffrior 
(Kii;s. |im; iiMil M>7). or itnffrior ami |MM*ti'ri«>r fliip. in •wh mm' rut 

liv liiiMtlixiiiii. tlh'si' ii'ijiiiir till' |in'-*i'ii( !• iif_ ^111 iif^istiint wlm can 
Ih' lliiirmi^'lily n-lictl u|miii to i»-\/x tin' nitiiv ju«t ImIoic it i« tut. 

Fw. 97. 

WhtTO there is time, ami where the soft jiarts admit of it. one of the 
inethuds with a vertical incisiiHi- i.ij. S|K'iue"« iiietl.od. the im raiiiuilv. 
or that, hv hiteral skin flaps- is far preferable, as (I) it alhiws of Mt-uriiif; 

tilt' aitcn: liffon- tliis in cut. tim.s (lispen.siiiir with the preliminary 
picssun- on the sul)( iaviaii. in many cases a (lilli( ult jnocechire. or tin- 
scizinj; of tiic artery in the flap; i'l) of e.\|>lorin^' the condilion of the 
head of the hone ; (."!) one flap can he cut h)n};er. accorihnj; to the state 
of the soft parts. 

Meant of arreitinK heemorrhage in amputation at the thoulder-ioint. 

Any of the following may be employed. The first two are by far the 

(1) Liiitilurinij or tiviatitui thv vessels on the itiiier fts/xi f i>f the limh 
hefnre the;/ (ire eiU (Fifjs. '.)'.• and 102). This method is an excellent one 
and suitaiile to all cases. The liijature should be placed as liij;li as 
possible, so as to <;et above the circumflex arteries, 'i'lie surgeon nmst 
be careful in the final use of the knife, high up in the axilla, not to prick 
the artery above his ligature. 


(2) Cowpression hi/ an nssixtnnt of the iiiji rior or anterior flop, and 
so of the rcssrlx hcfnrc tfiri/ ore cut (Fii;s. lOfi iiiul 107). 

(•"5) I'ri ssiirc on l/ir sufxhtvimi on it cro-isfn tin- firnl rih. Picssiiit- is. 
howev(M-. iilway.s liahli' to !»' inctlicit'iit in short, fiit necks ; in tliiii 
patients, however well applied at first with the thumb uiiled hy a 

I'lc;. !I8. hisai'ticiiliitiiin .-it llir .-liinilili r tlir liiiiiiiTiis hciiiL! frachircd 
lii-li up. 'riic ii|icrat(ir witli liis 1. ft lian<l the liuiiicnis <nit»ar(ls. whilr. 

Willi liis riulit. Iif (liviilrs tlu'caiisulc and insert ion of thr soa])ularis. (Fufaliciif.) 

j)ad(led key or weight, it is too often rendered unpertnin by the nerossary 
changes in jxisition of the limb durinfr the operation, a violent jfusii 
of blood at the last showinfi tlie suri;eon that his cDntidence in the 
artery being secured is misplaced. Furthermore, an assistant so employed 
is neceaaarily much in the way. For the above reasons one of the first 
two methods is to he preferred. 

(4) Li(j(itiirc of thr xxlu hivioii arterij. Cirrumstanres may render this 
desirable as in a case of .Mr. Howard Marsh's, in which he amputated 
at the shoulder-joint for an enormous " osteo-sarcoma " of the humerus. 


(5) Ligaline of the first part of the ii.rillinn arti rn. Tliissti'p. ori^iinally 
recommended by Delpech and more recently hy FroLssor Kct ii. may 
be used in those cases where a growth has cxt.'ndcd lii<:li up iiitu tin- 
axilla. A free incision between the pectoralis and tlie deltoid will then 
fri\ t> free access to the apex of the axilla, and enable the extent of the 
growth to he detprmint'd. 

((i) Wiivth's nu'thod bij pins and clastic tuhimj. Thi.-^ method will bo 
described" in the section dealing with amputation through the hip- joint. 


".lit. .\in|iiitalicin at tlic slidiil'li r ji'int I>y liil 'rii.-.-i' aiv t iiiin il 

ttsiJo. while tlif a.xillary artery w. iind l.y lursioti before (lisiirlieuliitimi is 
' oomplutcd. 

It is not recommended, for, unless the pins ar(> iiisertcil very exactly 
not an easy matter in operations of emergency the tubing may slip. 
(7) Securing the vessels lower down, in the Furneaux-Jordan method 

(.sw p. 20!)). 

(S) Use of an imlia-rnhher fnind. This is applied in the same way as 
that fully dcscril)cd in " Amputation at the Hip-joint." It is not a 
reliable methixi. especially in tiiose cases i>i a<ci(lfht ili wliith. tlic limb 
Ijcin;; mutilated high up. this operation is tarijely rc'iuired. For in 
these the band, being applied under the axilla and across the body, 


slips up as soon as tlio licad is d; -articulated. all«>\vin<,' of bleeding' from 
the vessels, and loiuiufi. it.solf. most incoiiveiiioutly, and as a ixwsible 
source of infection, into the way of the operator. 

(1) Lateral flaps. The patient having been propped up sufficiently, 
hiu.i^'lit to tho nluo of the t.ihle. and rolled over to the opp<>8ite side, 
the stiif.'e()n. st;iniliii<; outside the abducted limb on the right side, 
and inside it on the left, and haviiifr marked out with his left forelini;t v 
and thumb a point just below and outside the coracoid process ami a 
corresponding point behind (Fig. 97), then reaches over and, entering 

ri.:. 101). .\inpiitrttiiin at the slioulilcr-joiiit by tho f» ntqiidlr inothcwi. 

the knife in the axilla, close to the thumb, cuts an oval llap. about four 
inches long, consisting of skin and fascia from the side farthest liom 
him and eiidini; close to his linu'er. Without removing the kmfe the 

.sur^' I next niaiks out a similar llap on the other side, cutting from 

alMne dowiiw.nds. connn.Muiiii: just i)elo\v the tinker, and ending where 
the llap b.'gan in the mid-a.\illa. The assistant m charge of the 
lind) aids tho above bv rotating the arm into convement positions. 
The flaps are then dissected up and held out of the way. The vessels 
are ne.xt exposed, separated from the surrounding nerves, and secured. 
<'ither bv applving two pairs of Spencer- Wells forceps, dividing the 
vessel between tliem and twisting both ends, or by pa.>*siiig an aneurysm 
needle. tlirea<led with catgut, under the artiTV. and thus seeming it 
with two ligatures. The limb being then carried across the chest the 
outer part of the capsule is freely opened by cutting on the head of the 

.\Ml»l TATION AT Till SlIOl LDKU-.IOINT 203 

l)onc and th.' muscles attatlird to the outer tubenwity th..roHphly 
severed The limb is next rotated out wards, and the sub.scapulam 
tendon severed ; the bieeps tendon beinji cut ami the cajisule freely 
divided the joint is well opened on the inner side. I he hea.l l»-mn 
then dislocated,' by au assistant pressing the elbmv h.rward.s and against 
the side, the knife is passed from the outer side b.-limd the ateM 
head and. b.'int; kept close to the inner side of the bone, is brought 
out throiK'h the structures on the inner aspect of the arm. care bjMii}! 
taken, as The knife cuts its way out that it dm-s so below the pomt where 
the large ves.sels have i)een secured. 

In this ,„• Mi.v (ithi r ainpntatlou here for tuberculous or mnlipuint .tisease. it 
will I .■ ...r.lfMl lo .-.•.■utii.isc .■.-..vfully the eondition of the |mrts l. ft. to , l out 
a.iv L' wl»H.. r . nlarge.l or not. tojp'ther with the .nvnovial in. mUan.-. an,l n. 
soine cawH. to n-move tin- glenoid cavity with born- force|».. or prifi rably a tin.- simi |. 

(•_') Method en raqaette with preUminary exploration (Kaiabeuf) 
(Kj.'s. jiH) 1(>:5). In this imxlificution the jxHut of the knife having 
beiMi sunk ix'low and in 
fnmt of the ti]) of the acromion, 
an incision is made downwards, 
sutticiently long and deep to 
admit of expcwing the head of 
the hutuerus. The condition of 
the bone is then e.xphu-ed : If 
amputation is deciih-d on. the 
above is converted into one » /' 
nitjueftc by making an ob'i(|iie 
incision which from about 
the centre of the longitudinal one 
(Figs. KM) and 101) across the 
inner or the outer a.spect of the 
limb (according as it is right or 
left), and the ends lieliind on a 
level with the lower extremity 
of the longitudinal one. \ 
second exactly symmetrical to 
the first is next made over the 
oi)posite aspect of the limb, be- 
ginning where the first ended 
and terminating in the longi- 
tudinal incision opposite to the 
first (Fig. 101). The ne.xt step 
is the exposure of the artery 
})V division of the muscles. In 
the curved inner incisitm (Fig. 
I(»L' are seen the anterior fibres 
of the d.'ltoid almost blended with the insertion of the great iiectoial. 
This is raised with the finger, and the inseition oi the great pectoi-al 
detached from the bone. If now the \>m"V Hm|. be folde.l iiiward.s the 
coraco-bicipital fasciculus comes into view. The aj.oneurosis over it being 

> In any cane where tlie levonme of tile is wanting owiii): to this hoiw l.a\ in- 
U.-vn Imiketi hiuher uj», the use of Uon-force|>n will fat ilitate diMrtKulalK.u. 

Fio. 1»U. Ainputation .^t the rl.,'ht shouliler- 
joitit liy the ( M rnqnitlc »!■> tho«l. 


()]i(Mi('(l liy ii fifi' Idiiuitiuliiiiil incision, tlie muscular fasciculus is drawn 
over the front of the liunicrus and cut across. If an assistant now 
thorou^'lilv retract the inner tla]) the a.xillarv vessels and nerves are ex- 
posed." The artery should be i.solated and tied as liijili up a.s possible, so as 
to get above the posterior circuinile.x. The knife being again inserted into 
the outer oblitiue incision, the deltoid is boldly cut through as far 
as the back of the a.xilla. An assistant retracts the outer and inner 
(la])s. while tlie suil'i on o|)ens the capsule freelv. the liiid) beinsj rotated 
as ilirected (.sec p. :i(»:5). The head is ne.xt thrown out of tiie socket. 

I ifi. rii<' antoriiir fibres of thi' di ltoiil. tlic inscrtum of the pci (onilis 

major, iiiicl tlir toraco-bracliialis and hiiips have Ixcii cut. The left liaml of 
the operator drawn the largo nerves (lowuwards, and thus exposes the axillary 
artery for ligatui (Farabcuf . ) 

and the knife is carried behind the head, skirting the posterior-internal 
aspect of the iiunierus very doselv. so as not to cut the secured artery, 
and finally brought out through the incision on the inner side, severing 
the latissinius dorsi and teres major. If the artery has not been tied, 
an assistant secures it between his tlunnb. sunk deej)ly into the wound, 
and his fingers, which are in the axilla, or by using both hands. 

(.'{) Spence's method (Fig. 104). This excellent method is strongly 
recommended on account of its simplicity, and the ease with which 
the vessels may be secured. It is further especially suited to cases 
of failed excision,' or to cases of injury, e.g. gunshot, where the surgeon 
has to cut into and explore the condition of the joint before deciding 
on excision or amputation. By its means an excision can readily be 

' At till' pii M lit (lay, in eases of failed exeision. the .surjieoii will often prefer to make 
use of the uioditivatiou of the Furucaux- Jordan method (p. 2UU]. 


roiivcitfil into a .lisarticiilation. if this stop 1)p fcuui'l nmUnl. ft ha« 
otlifi- ailvaiitai:fs. Imt li-s.s iiii|i(iitaiit oin's : 

(1) The iM.stfiii>r (•iiciiiiilli'x ait.'iy is not'tl. .'xr.'pt in its 
small tcmiinal luaiulu's in fiont. wh.'ivas. I.otli in tin- laiL"' .l.ltoul 
flap and tlu- doublf Hap im-thods. tho trunk of the vcss.'l is m 
thi' oarlv steps of tin- oiH-ration and. n'traitiiijr. oftoii jrivcs rise to 
«'inl>aiiassin<.' iia'inorrhajie. 

(2) Tlic firvdt east' with whiih «H8articulation «nn bo aitoinplishca. 

I'ia. W.i. > t3 composiiii; tin- Haps ma'li ill till' I w r(/7«(/^i mclliod. 

(.i) The better shape of the stump. Professor Siwnce jiointoil out 
that, however e.xcellent are the result.s soon after other methotls, later 
on. till- shape of the stiini]) is nuich altered, not merely from the atrophy 
eommon to all .stumps, hut from retraction of the muscular elements 
of the flaps, the peetoralis major retracting; towards the sternum, and 
the latissimus dorsi and teres nuijor towards the spine and .^capula. 
Thus a deep, Ufjly holh)w results under the acromion. 

yi'j. l"r>s!io«>^ :M\ '<nM:m<i- of ill A < ISC (if iiiii I nitiil iiiii of Imtli liinlis ill II 
viiiiiig siilijcct. K. I)., iigi' lo. was acliiiilli il unili r .\ir. .laeDlisiin s care in liuy H 
ildspilal lora tn liMi . i usli of Imtli ii|i|ier c.\t remit leu, from hin hiiving Imi-ii run over 
l)\ a tinilM r waggon. .\iiiiPUlation was perfonned at onee tlinmghthe left Hhollkiff- 
joint by Hupcriur and inferior Aaya. An attviupt wtw made to save the rigfit hiiib, but 

. 104. Ampiitiitiiin 
it till' shouldiT-jdiiit 



S|H'nce"8 method. 


c.winc to cariLM' iM .-c tlint:iii.ani|Milati(.ii lifcaiiif ncoi'ssary. ami was iK-rformcd high 
up througii tiM l,u,n. rns l,v Mi. A. W light. The resulting projection of the Jrft 
luroniion from of' the in us. lis was well shown when, nine yeiira tater, Iw 

was aoia adnutted for a conical and tender stump on the right sule. duo mn' 
to the unbalanced Rrowth of the ui>|>er epiphyma. Ilie 
writing? Iielow lh«' ligiuc was done by the la<l with his teeth. 

(4) Piofe.ssor Koclier' points out that the longi- 
tudinal incision in this method has the advanta-re 
of being situated in the interval between two 
inwseular group.'* supplied by different nerves and 
that muscular atrophy is thus avoided. 

The operation is thus described in Professor 
Speiiee"s wolds: - " SiipiMising the ri<;ht arm to be 
the suhject ol amputation. The arm bein^' .slightly 
^ JA I ' al).liieted. and the head of the humerus rotated 
^ ]P > ^ / outwards if ])o.ssil)le. witii a broad strong knife 
yt 1 7 I begin l)V cutting (h)wn upon the head of the 

r I humerus, immediately external to the coracoid pro- 

I ! ppss. and carrv the incision down, through the 

K clavietilar fibres of the deltoid and pectoralis major, 

" ^ till I reiu h tlie luimeial attaciiment of the latter 

muscle, whicli 1 divide. I then, with a gentle 
curve, cany the incision across i'.id fairly througii 
the lower fibres of the deltoid towards the pos- 
terior border of the a.\illa, unless the textures be 
nuK li torn. I iie.xt mark out the line of the lower part of tlie inner 
section l.v carrving an incision thwuijh ihr skin and fat only, Itoni the 
point wlii-re niy straigiit incision terminated, across the inside of the 
anil, to meet the incisiim at the outer part, 
ill the line of union, but is not essential. 
If the fibres of the deltoid have been 
tlioroughlv divided in the line of inci.sion. 
the tlap so marked out can be easily sepa- 
r.ited (l)V the point of the finger, without 
further use of the knife) from tiie lione and 
joint, together witli the trunk of tlie ])os- 
terior circumflcK. whicii enters its deep 
surface, and is drawn upwards and backwards, 
so as to expose the head and tuberosities. 
The tendinous insertions of the capsular 
muscles, the long head of the biceps, and 
the capsule are next divided by cutting 
directly on the tuberosities and head of the 
bone, and the broad scapular tendon es- 
pecially, being very fully exposed by the 
incision, can be much more easily and 
completelv divided than in the double flap 
method. Bv keeping the large outer flap 
out of the way by a broad copper spatula 
or the finger of an assist.uit. and taking euro 
to keep the edge of the knife close to the bone, as in excision, 
the trunk of the posterior circumflex is protected. Disarticulation is 

' Omralirf Sitrg., p. 370. 

» Lancet, 1807, vol. 1, p. 143 j and Lee. on Surg., vol. ii, p. 602. 

This ensures accuracy 

Kui. UMi. 


then a.coinplislu-,!. a.xl tl..> liinl) r.'in..v...l l.v}; th.- r.-maining 
soft parts on the axillary aspect. The ..nly vessel vvhi. l. i« 
the anterior: circumflex divided in the first mkisi..,,. i.n.l here ,f 

necessary, a pair of eatch-ioreeps eaii he 
placed on it at once. In regard to the 
axillarv vessels, they can either bi^ com- 
pressed l)v an assistant before completing 
the division of the soft parts on the a.xillary 
aspect or, as I often do in cases where it is 
wished to avoid all risk, by a few touches of 
the knife, the vessel can be exposed, and 
then tied and divided between the two 
ligatures, so as to allow it to retract before 
dividing the other structures."' • 

(4) Amputation by superior and inferior 
flaps. (Figs, liiti and 107.) The patient 
having been i)ronj.'ht to the edj;e of the 
table, turned suiliciently over, and his 
shoulders supported by pillows the assist- 
ants are arranged as before. The arm being 
a little raised so as to relax the deltoid, 
the surgeon standing inside the limb on 
the right side and outside it on the left, 
lifts the deltoid nni.scle with his left haml, 
and sentb. the knife (narrow, strong, and no longer than needful) across 
ben(>ath the muscle, 
entering it on the right 
side, just below the cora- 
coid process, and bring- 
ing it out a little below 
the most prominent part 
of the acromion * or vice 
vemi. according to the 
side operated upon. The 
knife should pass close 
to the anatomical neck 
of the humerus, without 
hitching upon it, and 
the flap should be cut 
broadly rounded, and 
well down to the in.ser- 
tion of the deltoid. It 
is then raised and re- 
tracted and, the capsule, 
being now exposed, the 

joint is opened by , . ^ ^ j 

cutting strongly upon the head of the bone. The arm being now rotated 
vigorously outwards by an assistant or by the surgeon, the subscapularif . 

> Wht-re tbeliBtb Is very mnwtilar, Prof. Spence reoommcnded to n»i«e tho skin and fat 
from the deltoid at the lower part, and then to divide the miMcular fibres higher up by a 
seconil incision, so as to avoid excess of muMular tinae. 

a Unless care is taken to keep thus below the •eromion process there wUl bo some 
tendency for this bone to protrude in the wound. 

Fio. 107. To show the manner in which 1>1« i <lin« is 
controlled in the inferior flap : the axillary vessels are 
compressed by one thumb, the posterior circumflex by 
the other. 


thus niaili- tonsc. iiiid the biceps nro hiou^'lit into view iiiid wfvt>ro<l ; 
the limb is next rotatwl iiiwanls. imufi larricd across the chest, and 
the iniuc]cs attached to the great tuberosity are diviiU'd. Tlie (upsiile 
is then still more freely openeil. and tiie head of the bone, now freed, 
is puslied lip 1)V the assistant and pulled outwards from the glenoid 
(avitv. The knife is next slipped behind the head (Fig. KXi). and cuts 
its way along the under aspect of the neck and shaft of the humerus. 

so as to shape an inferior flap half the length 
of the uj)pei' one.' As joon as the knife is 

Eassed behind the bone, an assistant shps his 
ands in behind the back of the knife (Fig. 
KXi), foUowbg it so as to grasp firmly the 
soft parts in tlie inferior flap, and thus con- 
trol the axillary ves.sels (Fig. 107). 

The large vessels are ne.xt secured, then 
the circumfle.x. and nmscular branches that 
renuire it ; any large nerves tliat need 
trimming are then cut short, drainage, if 
necessary, provided, and the flaps brought 
into position. 

This amputation has the advantage of 
being very (|uickly done, and of giving a 
flap whi<h keeps in position i)V its own 
weight, and thus gives good drainage. If 
the soft parts below the humerus are 
much damaged, the upper flap must be 
cut proportionately long. 

(')) Amputation by deltoid or upper flap. 
This is merely a modification of the last. 
The deltoid or u|)per flap may be cut by 
transfixion, or made by cutting from with- 
out inwards. In cither case it nmst be of 
very full size, and thus is useful when the 
Flo. ins. Ainputation by axilla is damaged, but it has the disad- 
"''""■'^ vantage of leaving ne.\t to no flap in 

which an assistant can seize the axillary vessels ; and. owing to the 
powerful retraction of the muscles in the axillary folds, unless tlie 
upper flap is cut full in length and size, it will not cover the resulting 
wound. Finally, as the trunk of the posterior circumflex is cut, 
sloughing of the large deltoid flap may take place, especially if the 
tis.sues composing it are at all damaged previous to the amputation. 
Owing to the.s<> disadvantages which outweigh its rapidity, this method 
is not to be recommended, a short under-flap being always cut if 
possible. When the surgeon, having disarticulated, is cutting straight 
down, unable to make any Hap below, an assistant should try to 
draw up the skin of the axilla, otherwise, owing to the laxity of the 
skin in this situation, any downward traction will bring the skin of the 
thoracic wall under the knife. 

(<'>) Amputation by anterior and posterior flaps. 

This is only indicated when the soft jjiirts on the front and the inner aKiH'cts are 
damaged. The jiosition of the imtient being as advised at p. 31)7, and the limb being 

> The surgeon should not cut this till ho is told that the dap is held firmly ; and, in 
cutting it, he must be careful of his Mcistmt's fingen. 


carri.d wlmt .ipwanls. ba. kwar.I-.. a.i.l ....Uvanl-. lli.' snrp-on. Htajiding. if <m 
tl... I. fl si.l... lK liin.lan.l<.i.tHi.l. tl..> Hl.<.iil.l. r. . nt. is kiuf.' ju»t III Iront ol thf 
,-«.t. ri..r f.,1.1 ..f Ih.' axilla, tlunsis it a. ll... Im.'k of tin- huilM-riW «» Wttr thr 
h. a.l as ,H,ssil,l... M, an to K. t iu fn.nt ..f tli.' t.n.lon- of thf tm-H major uml lafiwin.ui. 
<l.,rsi. ami hriiiKing it out do»c to the ocroniion. cut* with a nawmg mov.-nu n . a 
flap four to fiv.- iuck-H bng.' which to next well retract,-* I. The '1 ' 

cffied »cro«i the che.t. the joint to freely opened U-hm.l. h.- mus. l. s "«" ''"' " 
the tubew»iti.-H geveiwl. the knife i««HeU betwH-n the lu a.l ami tl... Kl. m.i.l . av .l> 
(to facilitate this, the limb »honkl now U- curru.l ..v. r th.- .1.. st. aiul ll..- li. a.l ..f tli. 
bone punhed baekwartln). then U-tween the Ih.iu- an.l tl..- |» .■l..raliH major, an.l an 
ant.Tior Hai..-' f..ur im'li.'s Iohr. cut from witl.iu Ha nwiihan.' f...m 
large v.wU in arivst. .! .'itlaT l.y an assistant ^raspinj! t ns llap as it is < u . mii. li as 
at p. 2(»7, Fig. 107. ..r l.y tl». sur^.-m isolatii.K 111., axillary Is (tl.r 
<-oraeo-brachi.,lis will «ui,l.' lii.n). an.l s... nrinj! tli.-n. l.y t.asi.m "'^;.< --'^, 

U-for,. he oo.npk t.'s tl..' ..,M'rati..n l.y .uttiiiK tli.' ant. ri..r lap. W hen ' 
tl,.. riKht litnl.. th,- imtioiit In inK ti.r.u.l «. ll ..v-r to hw left wde. ♦ ; 
sta.KliiiK h..r.. insi,l.. tl... arm. which i« lieUI and backwardn ho aH to n-lax th. 
,>i.l. lifts this mus. l,. up with hm left hand, and tht-n paH«.^ his knif.' fi..m 1 st 
Ih.1.)w tlK- acromion, transfi-xing the base of the dehoi.l. grn/inK tli.' l.ji. k .. 
humeruH. and finally thnwts the i>oint downwanto am l-acUanls "••<'"^ ' 
Hkin till it comes out at the pcterior margin of the ax; la I Ins llap. f''"^ or I u 
inches long, shouhl be dtoiected up, the opened bthind, and the oiK-ration 
completed as before. 

(7) Ptirneaux-Jordan method.' This may lie nm.l.- iis.- of Imth as ft 
primary and ii secondary amputation. The followui}; aiv suitable cases : 

(a) Certain eam-H of injury. When-, though tl..- parts al...ut tl..- -h....l.l. r- 
jointB are intact, the humerus: is l.a.lly split up the I h.- soft pa.ts a . 
divided down to the bone by tlu- circular i.i.-tl.<..l thr.-.- t.. four .n. h. s - o« ..j 
axilla, the main vewieto secured, and the humenu. theii sh.-IU-tl out b>' '| «''»^'' 
incision along the outer and posterior aspect of the hmb, meeting the circular one at 

" "fh) inSscs of failed excision. H.-re, after an. put at i.)n of tlu- liml. l.y tlu- .ircular 
m.-th<Kl. the rest of the boiu- is turned out through tlu- cx. isu.n wound prolonged into 
tlu- circular one. „ . „ 

(r) After amputation in the middle of the arm in some caseH. A.ff., when tn< 
stump to the seat of osteo-myeUtis, necrosis, or otherwise doeH not do weU. 


This operation is but rar.-Iv poif..rm.Hl : (1) Owinjr t<» tlu' .•oi.i- 
parative infrequency of disease of tlie above especially ot tulu-i- 
culous disease, which requires operative measures ; (•->) from the ta. t 
that epiphysitis and infective synovitis usually give, after free incision 
and draiiia.'e. as {jood a result as can be obtained after excision J his 
is niainlv t.. the fact tliat much of th.- stiifiiess that otherwise 
would be present is made up f..r by the suppl.-mentarv mobility of the 
scapula, especially in vouii^ subjects. (!.-n.-ially sju-akinj:. th.- ..I.j.-cts 
of the operation will be for the removal of a tuberculous f.u us. t.. impn.v.- 
the mobility of the joint, or in some cases for the relief of pam. I li.' 
above remarks l.-ad up to the consideration of the amount of mov.-m.-iit 
which is .mined aft.-r tli.- operation of excision. The arm cannot usually 
be abducte.! and elevate.l bev..ii<l the lu.iiz..Mtal line; too often it lies 
close to the chest. Even if the deltoid retaiueil its power of elevation, 
it could not often exert it, as in most operations, owing to the amount 

' In the posterior flap will be the posterior pari of the .leltoi.l. th.- latissimus ,l„rsi. an.l 
ter.-s major. ^^^^^ ^^^^^ ^^^^ remaining fibres of the cleltoi.I. tlu- pectoralis maj..r, 

and the lar(ic VI sscl> ami nerves. , i,- • ■ . 

» For the details of this mcth..d see " Aniputelu.n at the ilip joint. 



of boiic reihoved. tliu fiiUrum of the hetd of the hnmenu against the 
glenoid cavitv )ia.x gout-. 

Sit 3. E. fcruhfion' Mixiko ot tlic four iliiff inovi'iiu'iits of tlio hIkihUUt- 
joint, via. " (I) abduction and elevation, (2) adduction. (.») and (i) inovo- 
nients in the antorior-posterior dircction-^ thme are requi«ite in ail 
onlinitcv tntdcs for tin- iruiilaiuc of tlic liiind in most of the common 
occupations of lif<'. The iiio\ ciiicnts of cl. vation nre seldom rei|iiiml 
8avi' liv tliosr wlio follow climbin;; ot( U|iations. as sailors, masons, lev. 
Now. tlif mtide of iM'rfonninj; tlif oja-rafion. as well as the o|M'ration 
itself, will materially influence these different movonienf.s. 'I'liiis. if 
the deltoid be cut completely a( ross, the ro>wer of aUliictioii of the 
arm and of its clevnti<m will !»■ ixmianently lost. If its fibres he merely 
split by a hnifiitiidinal incision, tliey may he re;,'ained in preat part.* 

"All those movements of rotation. Ac., which are de]>en(h'nt on 
the action of the muscles that are inserteil into the luherosifics ot the 
humerus will he permanently lost ; for, in all of caries of the iiead 
of the humerus rc(juirin}; excision, the surgeon will find it iiecessir ,' 
to saw through the bone below the tuberosities- in its surgical, and 
not its anatomical, neck.' Hence the connections of the supra-spinatus 
and infra spinatus, the teres minor, and subscapularis will all be separated, 
and their action on the i)one afterwards lost. Hut those muscles which 
adduct. and which give the iintcrior-posterior movements viz. the 
coraco-brachialis. the hiceps. the pectoralis major, lati.ssimns doisi. 
and teres major will all ho pre»er\'ed in their integrity; and hence 
it is that the arm, after this excision, is capable of guiding the hand 
in so great a variety of useful underhanded movements." 

J)r. SciKldiT ill 11 ])a]i< r on i-.xci.sioii of tlio sliuuldi r-joint.* has collected the late 
results after this oiH^rat ion in nineteen eiines, fifteen for injury and four for tufaerculolu 
cUnoaso. "FoUowiug tlie fxcii<ion of the upper end of the humeruii there will be 
limited power in the whoukier ; n distinct diminution in strength ; muscular atrophy: 
pomibly the formation of plaques of new bone about the old joint from detat licd 
periosteum. TheHe pieces of new bone may seriously inijiair the motion. Dcfoimity 
and jtain may follow an escioion of the Bhouldcr-joint. . . . After injury the 
rvsult following an oiH-rativc reposition or reductitm is better always than the 
result of an exfisiou.'' 

Indications. (1) DitTerent forms of arthritis disorganizing the joint, 
resisting careful treatment, in sniijects age. general condition. &.(•., 
are satisfactory, viz. {n) Tuherculons disease, resisting other treatment 
and, as in all excisions the stages of advanced ca.seation, .sinuses and 
mixed infection shotdd be ante-dated. Another reason for early 
excision here is given by Watson Cheyne and Burghard : ^ " Shoulder- 
joint disease is very frequently associated with or followed by disease 
of the lungs ; the exact connection of the two is difficult to understand. 

' Siinji ri/, vul. ii, ji. -."il. 

* Prof. Loiigmorc (Ri-^tcliuii nj tin Shouldtr Joiiil hi Militury Siiiyiri/, \>. i2)»Tite.H: 
" The loss of the elevating power of the deltoid must be accepted, like the losii of the 
rotating power from the division of the muscular iniscrtionB into the two tuberouties, 
as a necessary consequence of resection of tlic head of the humerus. But the ^u|>)1o^ting 
power of this museli' i xcrtid uiKin the whule iiii|icr c.xtiTiiiity owiiii.' to its (losition, its 
extensive orisriii. and the iiianni r in whic li it riiilira< c s ami iirotci ts the mutilated i>arts, 
as well as its fac ulty of a^si^til]^.' in ( ariyinL' the aini Ijatkwanls anil fin wanls, arc all 
functions which may still remain, and ser\c to point to the great imiiortaiiec of preserving 
its integrity as fully us po^-siUe." 

' TTiis opinion ajiix'ttis to be too definite and inelastic. The reader is referred to the 
remarks lielow on the site of section of the bone, and on subperiosteal resection (220). 

* Ann. n/Siirij.. vol. .xlix, p. (iiMi. 

" Man. of Surg. Treat., \i>l. iii, j>. 237 


bnt it is certainly a clinuiil fact that a larj:." iiiinilHT of |>ati»'nt(« 
suffering from this atTcitioii .sulTcr aUt Irom plitliisis ami. in a verv 
cunudcruble |>i(i|M)rtion, the luttor utTft tiiMi only o< ( ins alt. r ih.' joint 
diiieaae has luutwi for some timo." (h) DifMjrjfaiiizatioii of tin- joint 
after rheumatic fever, jpmorrhccal arthritis, wreiiihes. &v.. n'sultiiiji in 
cripjiliiiu aiikvloMlM, in a young subject, (c) Epiphysitis, or infe<;ti%i! 
arthritis wlu'rV th<" long «<mtinueil siipptiration is exhausting the ptitii-nt. 
and tlic outlook as to natural cnrc is not good. 

(2) (Junshot injiirifs, whi-ro the large vi-sscls ami m-rvi's havi" .'scaiifd. 
where fragnicnts of shfll. hnllcts. an- lo(lg«'d in th.- Ii.'ad «■! tin- 
Ixme, especially if the shaft of thr 1 is not inm h daniag.Ml (.sn p. ;.'-j;t). 

(3) Compound dislocation and conipoiiiid frai tnre with much thuiwgi* 
to th.' capsul.' and cartilage of the head of the hone the larger veswis 
and nerves being intact. In some such cases primary excision is indi- 
rated, (ienerallv replacement .should be effected after i invfiil cleansing of 
the damaged pa-' Secondary incision may be re.piired lor suppuration 
or necrosis. 

(4) Some cases of ankyl osis, c.;/. after acute rheumatic or traumatu' 
arthritis and suppuration. Here the (luestion of operative int.'rference 
will niainly turn on how far the additional movements of the «caj»ula 
and hmnerus together have made up for the ankylosis, and the degree 

of atro])hv of the nuiscles. 

Ur. E.' Souchon, of New Urle.\ns, has dealt with this subject.' 

He oonHiders that operation is only in reicut ca.<.s in full miI> 
jet't.'* or ill jiiitieiits of »ufHcicnt age to ensure that the reinoval "if tin- Im ad nf lli.' 
hunu ras will not la- followed l>y too gn at sliorteuin(.'. It Is is|H ( i.illy iiidu il( d iii 
aultylosis following artlirltis witli u ra|(l<l vwirsr (dry. acute arlliriti>), olw rvi d 
sometimes ill sul)jeets affected with acute rlieuiiiiilisiii. and esiMcially iui(>rrliu;;ic 
arthritis; also in cases consecutive to su|i|iuratiiig trauiMali<' arthriti-;. In thcM' 
l ascH the aiikylo>i.s oicurs before the atrophy of the nuisdcs. 'I'll.' cases of ankylosis 
which shouUluot be operated u|M)n arc ^ (1 ) those with a fairly useful linib as it staiid.s, 
unless there is positive assurance of imjiroviiin the movements, esiH'eially those that 
are paiticularlv needed for the patient s work ; (i) where atrophy of the musoloii is 
liresent. The application of electricity and maiwagt) may be required for some tmie 
Ix fore it is decided that the operation will be ui)cle88. Operation is contra-indicated, 
enw-oittUy when the muscles are irretrievably degenerated, as is the case in a great 
number of old ankyloses, and particularly those following long articular suppuration. 

{'j) In some cases of unreduced dislocation of the head of the humerus. - 
In such a case there will be serious loss of |)ower and movenieut, anil 
not infrecjuently. especially in sub-coracoid dislocations, scveiv symiotoms 
of pressure on the a.\illai-v ves.s(>ls or the nerves of the brachial plexus. 
In • 'li a case, if of only a few wcek.s" duration, an attempt may be 
nir . to effect rediu'tioii by manipulation or by tractioti under an 
ana'sthetic ; the greatest care must be taken, or the a.xillary ves.sels 
may be injured. If this tlocs not succeed, an open operation shouhl 
be carried out and every effort be made to replace the bone by leverage 
and by dividing any structures which hinder reduction. Should this 
fail excision of the head of the humerus is indicated. 

While this operation is one of recent date In Kn;;lanil. crcdu -lioiild lie L'ivi ii to tlioM' 
siir;.'eoiis who have practl>ed it. vcars atin. elscwIuTc. Ca^'s will lie f.iiiiiil rcronle.l by 
Post, of New Vork. ISOl : by Warren, of Hiiltliaore. in 18ti!l. In Ccrnmny. 1-uiKcnbeck. 
Volkmann, Cramer, Ku8ter,"Kronlein, and others operated for recurrent Ublocatiou and 

' Triiih^. Anu r.Sir-- .l-w-ir.. ISOfi. p. 40!). 

- Keferencc may i.s made to a paper by Ur. A. J", .bmas on ' Did Irreducible l>is- 
looations of the ShoiiUlor " ( Ann nj Sing., "lOlU, vol. li. p. 


iilcl ili^liii'.'it Idii iif llii' liNlttPni*. M- rii|iiiT |MiMi-lir<l a Min i --fnl ( a-c nf IfWHtion 

of till' licail nf tlir liiitlH>mi^ wliii li, fiaiiiiii'il a~ Hi ll a-< <Ii<I>h at) il, wa> |>ri'<niii)( nil thv 
brarkial artrry aiMi thn«ti>niiit.' vaouK nr. A lull l>il>llt>gra|iky i* •|>jNiHlnl to Dr. 
8«Miclion'tArt^ii',tb«'li«iitunthi»»iiliji'ct (i i</t iujr<i,\i. 213). 

Mr. Hbvilcl brought before the McdicO'(*htmrgical Society' » man. 

('■mroki ft>mm. 

Via. 10!). Fk'lU of o|><'r:iti<iii in habitual diiilocation of the sbouliler. 


aged 45. on vvlioin he hud perfonned excision for a neglected sub-corucoid 
dislocation of twelve weeks' standing. 

( Iwiii^ tci |pifs>iiif (111 llic iiudiaii and ulnar luTVrs. the lialid was alimist lisrlcs^t. 
MiiilriMtc atti iiijits at ndiiitiou liaviiig faili'd. tlir head was rciiiovcd tliiiiiigli tlif 
aiiatoiiiic il iici k. tills silo hcilifj chosen in older to disturli the parts as little as 
need be. The end of the bone was made as like the leal head an ]ios.sible by careful 
rounding. Twelve weeks afterwards the ]iutifnt was able to rt-sumf work as a 
waiter. The nioveiiients of the shoulder were satisfactory, and the hand gradually 
regained sliellglh. 

Lord Lister published - two similar cases treated by operation, but 
somewhat differently. 

» Traiu., vol Uxi, 1888, p. 173. * lirit. Mfd. Jonrn., 1800, vol. i. p. 1. 


Mr. Pmiiw Ooukl ami Kir W. Wntswm Chrync Hhowwl cnm-n at t\w 
Medicsl »wwty.^ 

Rriliirtiim »a< in ifii li rii»<' rlli i Inl nfti r ilm-iiiii of nni'i li'^. In "n • i 
Ihc nirw "f innM in. iil h.h -cmk i|. f. . iim', ami lliri>- h.ii .1 ti iii|cii' \ for tin' 
lii'iiil of (he liunirriH t<i -ll|if(>iH inl. Itiii h. n- fmir iimhiiIim liiul claiwil U-lwci ii iIih 
(liHliM-iUion and tin- inhu linn ; it w.i- ni • ■Ifnl in llii^^ cum! lo fli-ar iwt IIm' kUhomI 
ravitv. and till' palii iit f iilid ti« .illrml Mil.-i .|iii iilly. 

.Mr. 'riiiirlinrn - im i-hI iIu- In .nl of tlif IniriM in- llimiiijli tin iii'.;h .il nu k. m n 
i a,-r diaiinciMi cI .1:* >nli' la\ ii diilnc it mn iiml frarluii' foi mat iim iif 

I aliii^. \\>- |K>int« lint that divi-iim at tclidotiH wiiiild lien- hiivi- Ufii iiuuiilk-Htit. mm 

hill h a d. for d Ik iuI. if i vi 11 lliiin ntliin-d. wiwkl not huvf MUti into the (tli iioid 


Mr. F. ('. WalliH tiultlixlHtl » a c«ho in whii h an m»lrmiiv«' (iMiditli.n w 1- fiMind 
at the (MM<nllon. tIu< iMlhut hiul hml a di-li>< iilon ..f thr Mniiilili t ivdiK. il tin..' 
wpfkii nficr tho Acokhnt. Tim joint was ankvl..-. ,1. Vh- imumi Ii h nf the arm ». rr 
WiiMt<-d «n<l iwnityrrti, tho movmu-nts i>f tin- . Il«.\v and wiixt joint m rv linnlid ami 
tho linjiiTH qnito »tiff. Tho limit was tin- »iMt i.f n. nraluii' |«aniM. W Im ii tlu' li< .,d 
of tho hunioriis \va« oxciscd. tlio onrd^ of tlic' Ih.k liial ph «, iv a.llii rrnt to tin' 
iiuior sido of the liono and 1. (|niri <l d. t.irliiin nl . .Ma>-,iL'i- " i-i Invim 1 iil.v. 'I'lio 
pntiont li)Ht ull Iht |M«iii, nirainod ^(mmI niuvi nn nts of tin- >lioiildi r joint, and mnltl 
again droiM und Iced hencK. The tinp'nt, rt-nmining »ti«, iitill reqoiwl her attrntkm. 

Tho most comploto conf ti'nitiuii on this siiliji'ct is i\ papor I>y Dr. K. 
Souchoii, of Now Oiioaiis. ( >poiiitivo Tivatniont ol 1 1 icdiicililc Dis- 
Inpatioii.s of tho Shoul(h'r-Joiiit. Kocoiit or (Mil. Siiiiplo or ( ■luiipliratoil." ' 
This elaborate study, hasod on l.jt casoH of oporatioii. ahouiuls with 
those details which are so valuable to surgeons wlio may have to deal 
with these occasional but most diihcult cases. The following are the 
chief conclusions of Dr. Souchon : 

" Tho antorior inclHlon is tho rniiti-. Hrdin iioti ol t In- di-lor,ii ion tin- more 
doniralilo o|)i'rati(m. booaiiso it |pri si r\rs the In ad and all tin- nio\. iiii iils ilr p. lulinu 
thoronn. Kodlioliim .sliould lio dono oidy in ra-i s wUi ir tin' In ad and u'li Moid 
cavity aro in yood rondition : wlii ii no o.\lrnsivi' di^^i c l ion-- li i\c to l>i' ni.idf ; « In 11 
it is oasily olVccti-d without any nrrat i ltort ; ulii n ;li.' ii<ad do.s not nnd to l«. 
trimmed, or tlio i^np to ho too dcoply .sco()|H-d or oidarni-d ; »lu a tho luail readily 
remains in plaeo, hut not too tiwhtly. All this, n'gurdlosii erf the time of BtimdinK 
of tho disliK-atioii. It should, liowevor, always Im- iittoiniitiHl cotwciontiotwly. Ufiiuw 
manv have rooectitl, pcrhapH, when tho distlooatiou could have betm n-tluml.* 

liisregiird of these ruloH nwy lead to necroHia of tho heud, roourronoo of tho 
diitkjcation, or in ankykMis, witli their inevitable conseiiuenccs. Ki scctinn .^hnul I 
be practised in all other oafie«. When iit donhl. it is prrfi iatile to n scct. Ho 
much to reHOct— I.f. when to saw thron^th the anatnmieal neck or olplii|m ly and down- 
Mrard outsido tho tuliorosity. or hori/oiitally on a level with tho lower inaiuin of the 
hend— must he (U tormiiieii in each ease ; it is U'ttor to removo too inueh than too 
little. Of eourse. all olTorls should he niaite to m-ouro aM-ptic n-MiltN. A nuxit 
im|x>rtant point is to ^'et primary union." 

The folli)iri)Ki arc Ihr cliiif (ItKldchs to ii(hi(li<n. (I) 'liio cai stile 
may be roplaooti by a tiiick fii)rou,s mass, el) Aillusioiis of tho cai' -de 
to the glenoid cavity. (•"!) Such complete lioaliiif; of tlio rout i i 1 lie 
capsule as to prevent roilintion. (1) Strong adiiosioiis Ijotwoen the 
new cavity and the neck or head of the humerus. Such bands may be 
adherent to the vessels and nerves {see p. 212). (.l) Sclerosis of the 
muscles, rondorinn tlioir section iiocossary. (<i) Alteration in the shape 
of the head of the luimoriis. I'stially .several of tlie above causes combine 

» Lanci I. ISiti. p. 474. ' M< <l. Cfirmi.. vol. xiv, p. ». 

3 Cliii.S(}C. Trim--., vul. \\\;. p. 2'.H. 

* Tniin. Aw r. Siiiy. .l<..<r.. IsllT. p. :!l I. 

' la young sulijccts reduction should always lie preferred to resedion, and if tlio 
latter i« employed the epiphysial cartibige should not bo injured if possible. 


to interfere with reduction or resection. Dr Sonrhon sl.ow.s that 
lunon.'st the difficulties and complications which may be expect.d 
.Inriii.' the ..iteration the chief are : A very thickened capsule or much 
lil.roir. tissu' ahr.ut the head <.f the humerus, necessitating a tedious ,u..sist..nt .K.zin-. The head may lie very deep and 
be adherent to th.' adja.vnt parts. the nbs. and the deeper the 
position the greater tlie of serious ha nmrrhape. ^^ hen thus finnh 
fixed, the head may be prised into its natural position by elevatois. 
scoops, or blunt scissors, and this failing, division of the bone may be 
neclful. the head being then lifted out by the above-mentioned instru- 
ni.'Mts or loosened with lion-forceps. In other rases it may be wiser 
to ren.ove it The glenoid cavity may be so filled up as to 
need refashioning.' The vessels and nerves may he across the head of 
the bone. In the manipulations needful to get tlie head into j.lace. the 
neck of the humerus may give way. , , , , r „ , :. 

(fi) In some cases where dislocation of the head of the hunieru.. s 
associated with fracture of the upper extremity of the bone, especially 
tliniii.'li the anatomical neck. In these cases reduction of the dis- 
locatiou l.v such an incision as that described at p. 215, combined W'lth 
wirin" or plating of tin- fracture will be preferable to resection of the 
fractiired head. Occasionallv the head is completely s.-parated. or it 
mav become detaraed .luring manipulation : under these circumstanc es 
it should be removed. Resection may also l|c cal ;>.l for as a secondary 
operation if union fails and the joint is stiff. I he small si/e of the 
n .per fraL'-nent mav render its manipulation a matter of difficulty. 
To overcome this the upper fragment may be grasped by Peters bone- 
forceps or McBurnev's traction hook mav be emjjloyed. 

(7) A few cases of growth {v.q. exostosis, chondroma, myxochondroma, 
myeloid growths, and ossifying sarcoma) connected with the upper 
extremity of the humerus. Whilst the priceless value of the hand 
fuUv justifies the attempt in some instances, such cases must be extremely 


A well-reiwrtcd case is one in which the late Sir W. Mitchell Banks = omlea- 
vouHKl to muc the upper OKtromity of a by the »I'P;'^ "f ''• 
humerus, the site of a sarcomatous growth ong.nally regarded as a ohomlron a. 
Aft"r™-moval in 1878. tlio growth ncum.l. a.ui in three years ha.l attained a 
very large size. liUint' up tl.e axilla a.ul exte.x.liug l.eneath the juM torals. An att.Mnp. 
wa.M mad., to excise the upp. r half of the humerus but owmgto thr ,nvolvem..n 
the brachial vr^^ ls a>i<l n< rvs this had to be abandoned and t he lunb was amputat.-d 
at the sliouUler-joint. Tl,ough the shock was severe, the patient recovered and was 
nlive and well two years after the operation. 

5Ir Southam^has recorded a successful case of resection of the upper 
end of the right humerus for an endosteal (mixed-cell) sarcoma : 

\ laig.. delloi,! llap was made, and the head and four inches of the shaft of the 
I,,,,;, riis r. inove.1. S x mouths later, the patient, aged 30. could raise her hand t.^ 

„ uth. and employ her arm for housi-hold work and m using a sma I 
l u ne Though.^ «lth the arm hanging by the s .le there was an interval of 
boi four inches between the acromion and upper end of the hinnerus, Uie distanoo 
cotll l^consiclerablv diminished by the action of the biceps and triceps. and coraco- 
braehialis. A good "illustration aceompaniea this mstruelive case 

■ If l,„tli the rrlrnr.i.l ravitv 19 refaMiinnr.1 and the head of the hnmeriw resected. 
Itn'l t he t wi) arc t lien placed in cuntnct. ankylosU is likely to follow. 
V rtinifol SuU s ,,pon Two Year*' Work in the Uvtrpo^ Royil Infitmari,, p. 8. 

i Med. Ckron., Jm. 1887, p. 291. 

KX( ISION (.1-' TlIK SlI()rU)l"-H lOlNT 


M ()lli..r> ,M.M,ti..ns a most i„t.Mvstinn rase .n which l.v early mtcr- 
M. Olher ' ,,.,if tli.- Imin.Tus foi a sarcoma, 

vcntion. resect....! of the uppo I . " ^ ^^^.^^^ 

central a..d s,Un.cnost«,l. savecl t.. th >. " ,lll„.,t-like 
r,. vears old. The growth .fj^ ^1,' . ..wellin, i..c,ease.l .n.t.ire of the 
having been i.uule clear, the upper 
half of the humerus \v,i> removed, tins 
step being thought safer, though tli'' 
ioint itself was not involved. iNo < i>- 
la, Iglan.lseo.ihlbefclt mthe ax.lla. 

Three veais later the condition, locally 

and generallv. \vas excellent. 1 lien- 
was no reproduction of tlie part - 

inove<1 The resected en.l terminated in 

a small osteoplivtic prolongation joined 

to tiie scapula 1)V a fibrous band Ihe 

lunneriis was thus unable to find any 

steadying point so ess.-ntial for its 

n,ove.uents. The limb was therefore 

a flail, but a very useful one thanks 

to the mobility of the elbow and fingers, 
and to a supporting apparatus. 

Methods. ( 1 ) an anterior incision 
(Fi.'s. I lo-l I.'.). ;■->) l?y a postenoriiici- 
sion. straight or curved. <:$) By a del- 

The first two onlv will he referred to 
at a.iv length here. The third interferes 
so seriouslv with the after-pow^r of 
the deltoid" that the indications for its 
use must be of the rarest. 

(1) Biidtiti-noriiirisioii. I he patient 
being n;iled a litth- over and tlu- 
humerus abducted f^''.;^'' / h,t he s i ,n. standing at the 

i^KUS ^.ta .p for th. U"*". 

> ifj*. uMprn fi'/., t. ii, p. ">y. . . i.,,.i;,„. f,,, 111 iust imtsiilc the coracoid instead 
2 The adCantusie ..f a., anten-r uk.s , ■ ' ; ' j i,„«-ular space 

„f f,.„,n 11... aon.n.i.m is 1 Hw- .lo, mnM '''i';''' t 1 J. a™ M the Posterior and 
or thronul. 'J- ■'"'V";''-. ''i:;; ;1 f, \!ra^^^^ i. loft intact, togctWr with the 

.,„t,.r of tlic '''"'l^^ :r he cxcenti^^n^ of . ,c t. m.inal lilamont.s to the x vessels and ""^''' ^Ufh .t< >f' n<l «itl.. M. dUi'T (/"'•■ "'/'™ 
a..t.Ti..r part n( ^ "^ ''"^ ^•">"'"« 

prefers the mci.»i.>n V""""'' .'^.^ ,, "i.Vs , t -.Uvays <■..,,■, -pond to the coraL.,id process, 
of thte muscle tho ahove "'^'''-^''^ '/; . , ''( , Wl.ero the soft parts are much 

and because the cphaho ' ' Xcted^ M to bring tlie deltoid into relief, the 

Fio. no 

1 ,u. Anterior ohliiiue incision 
for excision of the shonhler. 


retractors insertcl iind. if tlio arm lins hvon rotntod outwards, tlie 
bicipital proovc will usuallv he sc.mi Kiii^' at tl.c l)()tt(im c.f the w.niiul. 
The condition of this important t.iuloii will vary much: (1) It may 
bo normal ; (2) it may be surn)unded with tuberculous material ; (.5) it 
may be frayed and adherent to the bone ; (4) it may be ulcerated or 

absent. , , , . , 

The bi.ii.ital tendon liavin^' been identified, the capsule is opened 
bv a free ineision. the head examined witli the iiniter. and the incision 
ill the capsule n«".\t carried downwards alon^' the hone just outside tlie 
bicipital jiroove to tlie level at which it is proposed to .-^aw the bone. 
With a sharp-pointed, curved, periosteal elevator (Ki-r. «») the three 
muscles attached to the greater tuberosity are now carefully detached 

Via, 111. Separation of thi- [loriosti'um from the Rirat tulx-rosity, tlie hrm 
being turned inwnrds. (Faralxjuf.) 

from it. The assistant in chaifjc of the limb, by strenuous rotation 
inwards, brings each part of the tuberosity in contact witli the elevator. 
Tlie operator next turns his attention to the lesser tuberosity, the limb 
beiiiir now rotated outwards, and separates the attachment of the sub- 
scapularis. The left thumb, aided by retractors, protects the soft parts. 
The l)iceps tendon audits sheath, if healthy, are detached bodily with the 
soft parts and the perio.steuni on the inner aspect of the inci.sion. If 
diseased the sheath must be opened, and the tuberculous material removed 
with curved scissors or a curette while the tendon is carefully held aside 
w ith a l)lunt hook or aneurysm-needle. In detaching the tendons, and 
also, later on. in sawiiiti the bone, if this be done in situ, care must be 
taken, bv keepin<r the arm somewhat separated from the body, and the 
elbow a little raised, to relax all the parts of the capsule. I'lilcss this 
be done, the edges of the wound in the capsule are stretched tight, 

deltoid may be turned oiitwanU from it.s insertion, if viiiorous ntradiim «f this 
iiiii.-rlo doo.=t not suffice. 

' Karabeiif advises, to ensure the bioipital groove U iwa found easily, that tlie arm lie 
Itept midway l)etween abduction and miduction. a )i(i.-^ition secured by pkcing the hand 
(the body being horizontal) on the anterior superior spine. 


tlu- (injior is nii'l"-!- "n.l tlu-.v is .... room for working with a saw, 
knilV. or t'lt'vatoi'. , .y- iiov \ 

The bone mav be .livide.! i.. two ways: (I) (Hf-'- ^ 

bhmt .lisSor « passed umW the bo,.e fn.... w..h... o,.twa,.ls so as 
oJrr Lff parts; the bone is -n.pU.eb- sa^., tl.n..,h w, h 

fo.<v,.s a...l twist..! ...It. tl..' l.>v.'n..>; movements <. an Hesat.... o i 
touches wit), the k,.ile. a.,li.., this. The actual bone seetu.n i.;e 

Fui II-.'. S..| of the p riost. urn fi-.n tl>.. l- ss- r tulK ro.i.y. tl.o »rm 
biiiig turmii outwairds. (J-maljciif.) 

it will pass throufih the tub.M<.siti..s. a,.v .■..n.aii.ini: ..lis. i.i.'f i" 
h.- t..ber..sities^beinu thoroughly dealt with bv the !Z....fie. .') I 

•d is lirst th. ..t oiit of the wound by an assistant, w^.o p.ishes th.- 
lb w^^^ Ivukwards and holds the humerus almost ver .od 

and theL sawn oK. This n.ethod is rertai,.ly the easier, but disturbs 
£ soft p^rts more. The f..rn,er is po.fe.tlv safe. a...l ...flicts less 
dimaRe orthe surroun.ling tissues ; linaily. whe.v a.,Vvl;.,s.s is presen 
^maf be most difficult to the head out. S.r V . 1 ' 
other" hand, considered that this method is less precise, that it pv.'s 
I t Te . of examininfr the parts fully, and that the 
:,l;,..l'l..ay be- da...a,...l bv th.- saw. Y'^^^•'^■"Thf t™S e.fd 
the .soft parts sho.ild be s.rupul..usiy i.rotected. The truncated end 
of the sha?t should be carefully rounde.l ..« with a saw .■'-Jf; 
especiallv in the neighbourhood ot the nerves, .^^i' " l*'**" 

If trying to reproducf the shape of the old head may be adopted. 




! I" 

(2) As tuberculous disoase of this joint, which ah)nc is hk. ly to ncod 
access to cverv part, is not common, and as tho anterior method by a 
free incision mid the careful use of retractors allows of sullicient exposure 
of th.' parts (.i),Mat.-d upon, this method has hitherto been generally 
adoofe/l The .■xcellcnt irsults obtainable by ProleMorKochwi posterior 
curvedincisioii(Kii.'. Mm M1...V than justify atrial of his method. Professor 
Kocheni-uies a patient who. after excision of tlie head of the humerus 

1)V the al)ove method, was ahle 

to raise the arm vertically by 
the side of his head. 'I'lie 
operation was here performed 
for fracture through the tuber- 
osities with rotation of the 
head of the humerus. The 
.skin incision is carried from the 
acromio-clavicular joint over 
the top of the shoulder and 
along the upper border of the 
acromion to the outer part of 
the spine of the scapula, and 
from thence downwards in a 
curved direction towards the 
posterior fold of the axilla, 
ending two fingers'-breadth 
above it. The upper limb of 
the incision passes through 
till' superior ligament right into 
tlie acromio-clavicular joint 
(the strong fibres of which 
are divided), and in the rest 
of its course divides the inser- 
tion of the trapezius along the 
upper border of the spine of 
the scapula. The descending 
fascia at the posterior border 
of the latter. The tliumb is 

Fig. 113. 

Exoi»ion of shouMcr. 

Section of the 

limb of the incision divides the dense 

of the deltoid, and exposes the fibres ■. 

now introduced beneath the .smooth under-surface of the deltoid, so 
as to separat.' it from the deeper muscles (with which it is connected 
uwvi'W I'v lo(.se cellular tissue) up to its origin from the acromion 
and its poste rior fibres are divided. The finger is now carried along 
tiie upper horder uf the infia-spiiiatus muscle, so as to free_ it 
opposite the outer border of the spine and the root of the acromion. 
In a similar manner the supra-spiiuitus is detached with a blunt dissector 
from th«" ni)i)er border of the spine of the scai)nla. in order that the 
finder mav he passed from above underneath the root of the acromion. 
The loot Of the acromion, which is now freed, is chiselled through 
obliciiielv and.; with the deltoid, is forcibly pushed forwards With 
the thuinhs over the head of the lium<-ius. In chiselling thnnigh the 
bone care be taken not to injur.' the siii>ra-scapiilar nerve, ^yhlch 
passes under the muscle.s from tlie supra-spinons into the infra-si.mous 
fossa ; the nerve is also protected by the transverse ligament ot the 
scapula. It is desirable before chiselling the bone to bore the holes 
required for the subsequent suture. Instead of dividing the root of 



the acronuon. the formation o tl.o, .. tla, mav ^ 
»,v morelv detachin!: the scapu ar on,-.,, ul t -Lit " 
ti,is allows <.f a v.-ry firm union AH.. " 
a<.,on,io..l..Uoi.l flap. th. hoad of thobonc - , ' /, 

nnoor out.T an.l i.ostrror aspects, coveroa by the t.-nilons ot uil 
V rnal r tato s viz. tlu- supVa-spinatus. infra-sp.natus and toroH 
nthlo; musS. Ti,.-,. s,;, ta..'s of the«c muscl.-s aro also exposal. 
An incision is now inail<' ov.t tlic ■ " 

hoad of the bone and. in oiiloi to 
avoid unnecessary injury, this must 
bfdone arcuratelV. The arm l>ein<i 
rotated outwards, a liin'_'itii<linal iii- 
c'i.sioTi is carried down to tin- bom' 
in the coronal plane. ( 'oniincnc iml; 
at the upper part of the lip of the 
bicipital <;roove. it e.xtends upwards 
tliroutrh the capsule along tlie an- 
terior ediie of the insertions of the 
external rotator muscles and over 
the liiu'liest i)art of the head of the 
humerus, so as to exi)ose the tendon 
of the biceps as far as its attach- 
ment to the upper edjieof the <jlenoi<l 
cavitv. The insertions of the ex- 
ternal rotators are now separated 
from the ixreater tuberosity and 
drawn backwards. The biceps ten- 
don is freed from its tiroove and 
drawn forwards, so that its sheath 

drawn forwards, so lat it. s.n am Thoal3«v.-ropn.scnt.a(airavor. 

niav be inspected. I he whole pro- ;[';;■J,i,*,;,„t^^^';,^, such as may IK. 

ced'urc is made easier by carrying g^^cu-a after in. i.sion in tluUlnn. m 

11 _ 1 o.ifl nf thf til.. ai.r-iiri;iL' i)f rtdiMMintc ai live iiiKl 

r lie 

cedure is made easier by carrying g^^cu-a after in. i.sion in thiuinn. in 
the elbow backwards, and at the whom the soourin.M.f a.^^ 
same tinte rotating: the arm out- i;--; •::::'";X.:::Ki:!ct^ the 
wards. In this wav the entire liea<l „,,,„,r epiphv-sis. Hinu«'8 
of the humerus and the iih noid tossa present in front and in the axilla. 

.u s it is most in.portant to remove all infected tissues '■>.»" p^' 
; i se this exposure of all parts of the pint is the gieat 
1. t.Je of t e' .uethod. Moreover, this free exposure IS obtained 
« th Nvith the fun. tiou of the deltoid or other muscles 

f trihoul le i\-t another advantage over the anterior is. that when 
L disease i ihe head is limited ..r abse ' o„lv the posterior musdes 
r'oui t. be separated, while the anterior part of t»;«?«^P^»»J; J'j' 
coraco-huuieral band, and the subscapularis muscle «e preserved mtect, 


and in this wav tht'ro is no tondcnfy of tlie head of tlic hono to be dis- 
placetl upwards towards the coracoiil. whieli so fre.iuently occurs as 
the result of the anterior operation. The method is, therefore, especully 
valuable in partial arthrectomics. 

The deltoid flap gives more room, and thus facilitates the opera- 
ti(.n (•onsidenil)lv. l)ut tlie larger scar an<l. far greater, in fact almost 
total, iinnaiiinent of deltoid power, are such .serious drawbacks that 

it is. i\owaday.s. hardly ever used. 
If the head of the humerus is 
very much shattered, if the soft 
parts are much matted and 
thickene*!. if there is any special 
reason for completing the opera- 
V , tion rapidly, in the rare cases of 

X \ excision attempted for large 

y ' I growths, for the .sake of more 

( complete exposure, this method 

X may, though very seldom, be 

' made use of. 

Site ot section of the boa* 
(Fig. 1 1.'?). It being most import- 
■iiit to leave the hu!"enis as long 
as possible. not an atom than 
is needful should be removed. 
The section shcmlil be made just 
below the articular surface in 
every case where this will remove 
the whole of the disease, and 
wliere all the head must go. The 
advantages of sawing here over 
division through the surgical neck 
are: (1) A long humerus is left 
to be brought against the glenoid 
cavitv and aid, as a fulcrum, the 
actioil of the deltoid in elevating 
the arm (-') The .section is 
made within the capsule, after, of 
course, freely opening this, but not damaging its attachments to the neck 
of the bone.' (3) The tendon in the bicipital groove is less likely to be 
interfered with. In every case of excision, save the rare one for new- 
growths, it is advisable to begin by removing as little as possible, then 
plugging the wound with steriliseil gauze to test the freedom in abduc- 
tion, rotation. &c.. of the humerus and only to resort to further removal 
of bone if inobilitv is much restricted. 

The late Mr. J. X. Davics-CoUey has related > a case of partial 
resection followed by unimpaired movement of the joint. 

As, at the time of the operation, a portion of tin- liead of the humerus seemed 
healthv. and the disease consisted chietly of a curious erosion of the great tuln-rosity 
and the ailjaeent portion of the artieiilar sulfa c. these iKirtious only were removed, 
without ili^lccitiiiK the head of the bone. The part removed was ehlelly tlie 
articular Miiface ahove the greater tuberosity, together with what remaima of that 
process. Tlio lesdcr tuberosity appears not to liave been touched. Alxjut thri"c- 
lifths of the articular surfoce was left, being healthy. There was someerosion of the 
' Oup't Uotp. Sep., tliiid series, voL xs, p. 525. 

Fia. l\'t. K(K;her's |io»l<liiir iiuisioii 
for excision of the shoukler. 


bone below the epiphysial ^^^J^:;^^ ^l':': .nl^i'^ls liZr^'^'^^ 

ment ol the joint was pw-f. - t n. ''^ •■•>''''' , ^^.j ,,,,,l.„„ a,»l rapi.lity 

his head, and rotate* it uud iHTforiiis e\ i rj act idu \mi li as ).u h i k 

a8 with the left shoulder- joint." 

If the .lis.<aso cxtoiuls lower down, gouging .nav 1... tvsort...l to 
if , oe ul on,- tNvo further sections ntay be ma.le till UMy t.s>u 
a hoi .ut as iM tho .use ..f the elhuw, per..;steal aepus.ts o 

Lghenit^gs. uhieh will when the imtatton is re.noved, .nust 

not be mistaken for .lisease whieh .alls lor .xtMimt.on. 

The Blenoid cavity is tlie.i exannne.l and jiou^'ed. or its cartili!^< 
peekd cS St a bint knife, if earions. 'T/^;'?;''; ! ^ 

removal is caUed for must be moat rare. If really called loi. it m .> 
b e .' ted bv an osteotome, fine sharp saw. or cuttin, -"-f- ; 
after the -lenoi.l insertion ..f the eapsuh- lias been pee ed « 
den 1 hiM. level ; but taking away the glenoid cavitv must interfere 
Sh attaehmeius ..f the hieeps'^and triceps, and cause nsk by the opemng 
up of additional cancellous tissue. ,l,..|,,sis 
^ The above operation must b.- so.n.nvhat inodit....! m eas.-s .>f 'k . m 
and new "rowtl s. In cases of bony ankyhnsis the op.'.at..r in. , a.l.-i.t 

.^thf two foll.,wi,ig : he may divide ^v,th a ^^^^j^^ 
the line .,f fusion and then, the humerus being ™' ^.'•^•^ • '^''K 
oinnlete the .)peration .)n the Im.'s alr.> given; or. haNing sawii 
aZ«l th^hum.M•us in situ, he may .s.-i/..- the b<.ne with lion-forceps. 

01 drill a ho e i^d insert McBurney-s hook, ami strip -t ot its - 
capsula? covering. Much care must be tak... t.. put t e . 
throu-h its different movements before it is dec.le.l that sullui.nt l...n. 
has i)een rem.)V.-.l.' lest ankylosis recur. i.,,,,,,.,.,,, f„r 

In th.)se rare ca.s.'s .)f res.-cti..n ..t the upper end of the humeius lor 
new Vo tV p. tlH' op.>rati..n must be outside the permstetim, 
S?he vesseh ^ nerves will r.M,uii.- a.lditi..nal attention. Mon- 
J^ni MdU ^required now and. to gain this, the p.etoralis n,a|,.r a 
dXid may each be detached fr..m the clavic e. I lu- sIh.,.1.1. -Jo n 
itseH is ve?v rarelv invaded bv the growth. Owmg to tl.- r,Mn..Nal 
f the hum ..-.ts. which is necessary, the after-result is often imp.Mt^ t 
th.mgh if the insertion of the d^toid can be preserved, the hmb will 

A^Vv^srSich rciuire it. branches of the ..i.vundlex arteries. 
aretfJnr-SdJsinuses^are laid ..pen. tt.ber.-ulons t.ssu-. anv n-n.nants 

of diseased capsule and synovial iv,' n.l 

.leltoi.l bursa, if inv..lved. dissected out, drainag.- pimw ..!. an.l h 

,,e p ..f th.- w.iund closed. The drainage-tub.- sh..u 1.1 pass 
Iffi livsest part ..f th.- w.,uiul in fn.nt (wh.-ther this be within or beh.w 
Z capsule . by means .,f a ..ount.-r-pun. ture. t.. the back o th.- upp 
arm so that the site ..f the op.-ration may 1m- w.-ll <liaiiu- l whil. th. 
StLnt is recumbent. In maki.ig the cunter-puiuture. in.m withm 
Swards the close contiguity of the circumflex vessels and ner>'e must 

^'SlilJe'^ls!..!! has been performed for tubercnibus disease, with 
sinusi^l^ofoim emulsi.,n. an.l small tampons of i.nloform gauze, which 


has been kept in a solution of cailM.lic acid ( I in L'o) or Ivm-I (2 per cent.) 
will be eniplovcd. At otlu-r tinu's, win'iv flu' tissues aiv licaltiiy. tin' 
above tampon's will be mucli less uceJeU, and the wound nia\ lu- sutuivil 
in the upp.-r part. In everv case a trianfnilur pad of stt-rilized piuze, 
thr.-c or four iiu lics tiiick at its i)ase. should be placed in the axilla, 
and tlu' arm eartfullv secured to tlie side, tiie elbow beinj; kept a httle 
forward, and comf(irtal)lv kept awav from tlie tliora.s by a sufh- 
cientlv thick layer of .salicylic wool. The drrssiiiL' should not be 
chanfjed for five or si.K daVs if possible, especially in ciiildren. Alter 
the first dre8sin<r the limb should not be fastened to the sule. the fore- 
arm onlv beiiif! sui)ported in a sling. The tendency to displacenient must be m.'t bv a firm jiad over the front of the j<»int. The 
a.\illarv pad is of the <; importance and shoiiM be worn for six 
weeks." Otherwise, a lind) li.\ed to the side is almost certain. \\ here 
the parts are la.v, as in old tuberculous di.sease, the necessary inter- 
ference with the bone, attachments of tendons, &c.. has been extensive, 
less liberty must be given, or the new joint will be too loose. ^^hlIe 
the finpers and elbow-joint must be gently exercised daily from the 
very first, the date of connnencing movements of the shoulder-jomt 
will delH'iid on the lesion for which the operation was performed, and 
the condition of the j.arts around. Where tliese are healthy, when but 
little bone has been removed, where it is probable that new bone wdl 
be (piicklv reproduced, the date must be an early one. As a j;eneral 
rule it is" of no use to begin before the deep parts of the wounil are 
snflicientlv healed ; and this should be some time between the secoiul 
and third weeks. The chief points to pay attention to arc: (1) C'are 
in carrviii^' out abduction, lest the new head of the bone be lodged close 
to the'conicoid process instead of in the ^'lenoid cavity. C^) mas.sage 
and electricitv to the muscles, especially the deltoid and the muscles 
attached to 'the tuberosities ; (3) exercise of the rotator muscles : 
(4) making the patient carry "ut the movements of his humeiiis inde- 
pendentlv of those of the scapula— an end very ditlicult to ens\ire in 
the case" of a child or in cases where the ankylosis has long existed. 
The above must t)e dailv aii<l assiduously carried out, with the occasional 
aid of an aiuesthetic if needful. The iiractice of such movements as 
bringing a gun up to the shoulder, sweeping w ith a short brush, lifting 
and carrying light weights with the limb abducted, are vahiabh' aids. 

Qaestion ol subperiosteal resection. As one of the chief draw- 
backs of the operation is the poor anwrnnt of abduction and elevatum 
which i-emaiiis owing, in larL'«" measure, to the humerus being too 
short to be brought into the' glenoid cavity when the deltoid acts, 
it mav be stronglv urged that in this joint a trial of the sub- 
periosteal method should be carefully maile. to ensure as much rejiro- 
duction of bone as possible. Von Langenbeck ' gives more than one 
case in which the arm could be raised vertically, and the movements 
were excellent. While it is true that these were cases of resection for 
gunshot injmv. and therefore the patients probably healthy adults, on 
the other hand preservation of the periostemn is not likely to be so 
easilv elTected here as in those cases wiiere it is .softened by di.sease. 
Even if the perio.struiii r.uiliut be completely ].re'^rive,!, an ;ul<lit!<J!!al 
half inch or inch in length gained, and an irregular knob or iiodule-like 
mass which may be moulded into a rudimentary head within the new 
» Arrh.f. klin. Chir., 1874, voL xvi. 


capsule, mav tnnkc iniuh clilteronco ii. tlu- futur,. inohility and us.-ful- 
uiL (.f tl..' liiul). M. OllitT ' fiKures and dt-.-wribw a 8iMH iin.-h ..f a nvsocted 
liuiiu'ius iiiii.' years after the opration. 

Tho mtirnt. a t. Jti. Iiiui Im.l mixol.i.-f «•> H"' f'"' '"" '^'v. 

HUnnnraH > " .1 livr lis.ul.,.. Kiv . . ..t i,n, t n - of , I,. l.uM. rus. .". aMUvl fn-n, 
mipiMll HI ■ ,,.„,. .1. Afl. r thr Ml.. I Itlnll ll.' «nH i.l.l.- !<• foil"" l"> 

' I «u • ,;:,";„:,i, , .,mmiv ^i.n i,f,in, «,.i.h... t^.. 

oi 1 o tl ■ l.n.M. .u. was ,n< .inUvW . N|.a.ul. .l. numrnm-. \H^->> mvl>W\m-^- 

.Lmrin.o Xh .1.. ins.„i..n ..f .i„ , an.l .litl.Trnt m,.H-l.^ om.ld In- to\M. 

Treatment o! guiuhot injuries o! the ihonlder-ioint. Lieutenant- 
Colonel Hickson, R.A.M.( ' ,- writes : 

"Fro,n tiM- small nnmix.;- of r..,mrfa n.son. «..,ni,is .,f ! i'';;;" 

n-lutivolv ran-. Only twenty-wvu l.av,- U-m I,„ 1 „n. « . 

wrforatioiw und cight.'.-n (■..niminut i..i.s ur li>sntvs ,.t n,,.i..m^ „f ni>. 

".r'.Trpti<- mr^s as,.^^ .n.l , h. 'n .nam,,,, on,.. i„ M ,n,:..y a,„,,u,.tum 

iiri.v'i'il fital has Ihcii i liissi'd a'^ (loulitful. 

' As in otl>, r j-.h.ts. tl„. isMK- ..( 1.U.V ,» rf..n.t.«n« wn« m.«t 

fav . u al io Kijrht ,.f thes.. .as.s r...-.v...v,l without any «,MT..t.Y'„r..s 
I s rv. tl». m.atn.,.nt ronsistinB of aotis.-ptio dn.H«.,«.. with ^ • ' " > 
i,,.. a . ptic throu^'hoMt. InoiHkm for the extraction of a n-tHin^l l.ullot . i t 
;io:^al ngUm «as r,..,uir.d in one cane of ,K.rforation ; a. th.« .as,- al«. <IhI 

'""'i^cLmin,.,,.! Fractun.. Th.^- rrs.,lt...l ..itl..T fron, serious fray'mvs of th,- 
upper end of the .liaphy.sis of the hutnenis with hssui. s , xt, n.lm..' in - tl„. j n,l. 
Km the im,«et of the larger-lKHv LulMs. s,„ h as H,,- .\l,„.,n. II. Im-m, 
expanZg bullets, or fron. frag.neuts ..f sl„ II. The ve. v ,l, st,u,-.,v.. n , .nv s,. ,a- 
of C Injuries of this type will U- s.. .. fr.„n ,1m. tar, ,i,a, „, - 
oases of this .[..scriptiou of xvoii.uls. inlrlf.-irn. r «a> .■.ill .1 loi. ^I^''*- 

1 m- eases neov. V f w. ^l the removal of fiaf:,n. l.>s ; ... . it-'h,. exe.s.on of tl.e 

,'Vtem 1 . f tl.e h...,.e,-us was s... .rs.f„lly earri...l o..t ; ,,, to... . a...putatH« at 
tl shm .ler joi.U was n .p.ind. ">.■■ of <li'-«l. ""d in one Ik.rgei; » iiiterseamilo- 

oraeic . , i..u was's..e. essfullv ,Krfor...e<l. The two n-m| easeH which 
r -o -e vd^w^ h^^^^ anv operative moJutvH we«, the two ex.unples of eo,,,- 
.u io, s. w 11 Ik- sel n fro.u the above analysis that e ther ,«r,.al or eo.uplete 
i n o . or amputation at. the «houIder-joint wa» carru.l '» ^.i;*^ 
co>u>..i,u.tions out of a total of eighteen such wminds, or in neariy ono-half of tho 
to, il nuiuber of reported cases of ev. iy variety. 

The following advice of Professor Oilier a.s to the treatiueiit of gun- 
shot and other injuries of the shoulder-joint wdl be found moat useful. 

H tl... Ina.l l»- f.a. ,.... ,1. a.ul noi in more than two or three fragments, 

ami if these a.v li.'l.l tofr,.,l,. r and not widely .separated he would trust to ant i- 
s'psi. . If suppuration o.c.Ted. I,.' would advine re-sc-otion ; and he points out that 
a le erred exei.sion ha. one adva.itage, i.e. that t ine may have elapsed for inHamma- 
ion of the periosteum to have occurred, and thus its osteogen. . ;o pro,K.r,.es may 
. uoused. If the head of the humerus te badly shatfred aa.l , 
ueh separated from each other from ti.e.r perios......... le . I" ' ';"' ^ 

nrimar^• exeision. endeavouring to re.<hape th.' ex„vn..,y into a n « 1m ..d. f 
!lu s,!iinteri..g a.ul .lamage to dm-s not atfeet ...ore than three or four 

» /.of. (•//.. t. i. p. :!.'". t. ii. p. 

following experience of the Result's of s,..all l.i.ll. ts „f ,i.l> n.-I... i.y : - \\..u:m1s ..f tlu. 
aAicuktiou were bv no means e.,.,......n. This .l, p...Ml. .1. 1 think. ..i. tw.. p.-ints ... the 

arehHretZ of theW : f.r.t. a hull. , ,.. e,„er tli. fnmt ,.t tli.. eavty a.i.l transverso 
^rA'l', n^?i„ fn ..m., with a , xa.titii.le fi..n. tlie i.,.>n,..hate front; secondly. 

the ioint needed to come with a i;.. at . xa. titii.le fi..... tl.e, . hate front ; secondly. 
w.«. r re.^u!;i fr,..n a pun ly lateral dire, tin,, eal, .dat.-d ,uere.. the head of ho 
C .1.^ .^..d th<. .'I..,,.,i,l . avity were naturally of very rare .Ke..rrenee. W o„„ds of tho 
rom .^ennip f the sh„..lder reeeivcd while tfco men were in the Pr"'"' P'-"^'" »"--"°t 
SSZmon. but it wa. remarkable how rarely the shoulder jomt wa« imphcated in the«o. 


.■, iitiiiu tr.-« of it. all the tlamagt-d bom. m«y be iweotcd ; if tho lu. f vxU mU 
lom r .lowii. m,nw ri-k must Ik- mil nml tlic injun^d bof"- I. ft. 

thohu^orUH with ,liHl.K...,„n. If |...t ..f Ih.; lH;«d Im.l . s..,,,. ■ hr «.m.U 

Lave tl.i. atta. hr.l t- thr ^l,aft. H. n.ov.l of HplM.t. rs ''r''/- ''''• ^ '''7' ; . ' '"^ 
dom- with tl... >, sl .an- of IIm' ,,..,>„st. „,„. , v, ry atom of tins LrinK Irft > th 
wound Willi, la.ll. l m.iv In us.d for .liai.mur. it is rar. ly well to .•iilarg.- 
tli.'iii or to throw our into aiiolli.'r m. as to . iiiplov th. iii as the o|H'ratlon wo^n" ' 

his sliouM I..- Ill ..I.' i.. tlir iiMial |.la,v. With fgar,! to tlu-,wriltiv.' valuf of 
pniiiarv aii.l lat. r . x.-isioii. I'lof. l.lli. r allows that bone |WiKluctK» W I.-sm hk. ly m 

!„■ forin. r owinj? to llu- p. riosi. inii hriiiK miiiittttiwed ami more difficult to say.'. 

,1,,. .„l„.r l an<l. he iK.i.ils out that, a- yet. we scareely k.u.w what ""'"h'T' - 
,„, 'e u«e of |.ro,H r |k riosteal elevators will . tf-. t. >^>" 

primary rei -'Cl- .,r guiwliot injuri.s the imtuiils are usually young a.lults. aii.l 
their muneleM in e.\cellent order. , , . i . i ,. 

In the case of gtiwihot and other injuri. s in wliu h tli mmpo is not limit. . 1 I.. 

tlK- head and surgical neck of the rus, hut s,,linl. rs tli.. upis r half or tl,l. .■• 
nlrte^H of the humerUH.r.Mection is still u»:, .lhy l'r.,f () h. r ( .»/,r„) as ..ntras 

VcKoft parts are Huffieiently «mn.l t.. surviv.-. Though th.- fuiutioi.o a liml. thus 

"reserve 1 will Ik- v.-rv imp..f.-. l. th.- r.-siilt will I,.- far sup.-r,..r tothat of amputalxm 
i, th? shouUl.-r.j.,ini In any sM. h r.-s.-.-tion th.- anfs.-pti.- I'"'-'""''""* "ho"" 
Ih- as ,-omph-t.- as ,K,ssii.l.-. m.i.1 any lo.i« splint. rs. >slm-h. ^^' YV i.'rh^„id 
Hhatt.-i.-.l. pr.-s. rv.- th. ir r.-lati..n t.. th.- ,M-riost.-um should Ik- left. a». with th,, aKi 
of the Urn.- pr.KhK-li..n ..f tli.- ,« riost. um around them, th.-y will maintain the 
continuity of the Ixtiiy ooluiiin. 

BMnrrent diiloc«tion o! the ihoulder. Dr. Btirn-ll and Dr. Lov.-tt. 
of Boston, have contribtited a paper on this subject, with si.x 
two of wliit li were operated upon, with an e.xcelleiit result m each case.' 
Amongst tho i)atli<>loni(al tonditioiis. which vary widely, these wntere 
consider the following to be established : 

(I) Laxity of the capsuU- ; (2) Tearing away of th.- .-apsiil.- from th,- gl.-noi.l 
cavty; CI) and 4) Partial fra.-tnn- of the li.-a.l of th.- hu.n.riis or the glenoid 
cavitv (.-.) Tearing away of inustular instrtioiis. or rui.ture of the 1,k-,-i». ten.loii : 
(.1) Alt.r..! shape of tho head oi the hamenis, probably the result of chronic^^ an- tlu- . hi. f steps of tlie oiH-ration performed by Dr. Burrell in 
ih.- 1«.. eases 1. f. II. .1 t.. al.ove. Where a trial of primary fixation for a few wcekg. 
,„mhin. .1 with massag.- of tho miMcle*. foUowed by careful moy. ments ,)f the joint, 
fails after ten weeks. i)artial renection and suture of the caiwule - is ri .-oinmemlecl. 
unless any abnormalities be found which n>quire removal of t he head of t he hnni. rus. 
A fiec inbision having been made in the iK-ctoro-deltoid int.-ryal. th.- ..-i.hah.- v.-m 
drawn asWe, the coraeo-braehialis and bicei* are recognised in the upper an. tli.- 
pectoralis major in the lower ,.art of the wound. Division of the u|.!h r tl.r.-.- 
{marters of th.- insertion of the latt.-r nuis.l.- is re.-oinm.-n.l.-d so as to exp..s.- 
thoroughlv the lu-a.l and n.-ek of th.- l,.m.-. Th.- t.-i,.l..n of the l.i.-.-,.s will 
s,-,-n and felt through its slu-iith. Th.- in. i>i..n sh..ul.l 1..- .-arri.-.l m its w hoh- d.-ptl 
up to th.- coracoid process, and th.- t.-n.l.)ns ..f t h.- l,i.-.-ps an.l .•.)rae..-bnichittli» cl.-ared 
ui. t.) this point. \W r.)tatiiig the h.a.l and dropjang it Uckwanis, the 
ins.-rt i..n ..f t h.- sul.eupularis is streteh.-.l ov.-r t h.- Lone. A i«rtion of this insertion 
^houl.l I..- (livi.l.-.l. Tlu- arm is next abduet.-d. raised to a horizontal jiOHition. ami 
th.- h.a.l of th.- l».n<- pr.-ss...l backwards so as to pre-vent its coming up und.-r th.- 
■•.,ra.-..i.l pr..e.-ss, whieh it tends to ilo in these oases.' and also to relax tlu- froii of 
tb.- easpiile. If the joint apiK-ar normal the loos,- part of this ligami-iit is tlu-n 
ErasiK-d with vulsellum force,*, and a fold thrc-e-quart.-rs of an inch m length and 
tl.rei-cighU of an inch wide excised. The gap is then sutured, reiulering tlu- capsule 
distinctly tighter and shorter. . , , , . , --.«,„ 

Mr. Southern • published a case in which he had excised the shoulder-joint for a 
frequently recurring dislocation in a woman, aged 45. 

>^ TraiiK. Amir. Surg. Atmc. lHiM,ii.-2'X\. 

a Thei-r.-.lit .if lirst takin;; this step is.liie to Dr. C.-rst.-r, .if N.-w \ .irk. 
» Two .l. tails in th.- uiK-rative an.l intendcl t.. meet this clisplacemeiit 
an- (:iv(-n at pp. 2l!t. 

* hril. Mid.Joitrn., I8!t2, li, p. 

FUAcrruKs ok tiik in'MK.nrs 225 

Nolhing abnormal. b.-y.Mi.l nliRht Rralinn. Ik. .l. t.M-tnl .... ..xa,,,i.mtion. 

'**A?tto'IIJ?mtio,, a H,.,all part of ll.,. a>.t, ri„r .,... ..( ll,- «!, I .avity «a. 
abm>nt. TV ht-ad ..f ll.r l.i...i. ru.H «„» n.wi. llina.^'li !Im' a.mlonun.l ... . k ; fivniU- 
po^T"*. n'ZZui. w.r.- IH ,u„ tl,,.,. ks af..r .I,- ..|h rat...... a.ul. Im 

a .T. tl..-r,. h..! I"-. .. .w. .. . nr., ,,, ,- of t n.l.,. at ...... Th.- ..rm w..h .Ih-i vpr 

u«.(ul. wilh8.HKl ,..ov..m. iits. II... ,.ati. ..t 1. at.l.. t., ,h .-f-.r... h. r 
hold dutk-R. 

Operative treatment o! limple Iracturei ol the upper extremity ol the 

humerus. In tli.'s.. i.ij.iri.-s.!y fractures of tl..' suiyK^al t..-.k 
i.n.l thn.ii-'h of til.- tiil..'f..siii.'s. it may. owm« to tlio Hiimll Mze ol 
tl..- .1I.I..T f.aj;....'nt. 1..- i...i....ssil.l.' t.. s.-cmv h<mmI iMwitioii by mani- 
piilati'.li. Owi.,- t.. til.' |..-..xii..ilv ..r tl..- atti.nlar «ur ac. wl.i. l. may 
itsolf be iiivoiv.-.l. ai.v .•xi-o«.s of .alius is liU- ly .s.-i ioii.sly to impair tl..- 
mohilitv of thi- joint, ruder th.-s.- . ir. Ui.istaiKM S. it ll..- aj;.- aii.l -- "'.-ta 
.•..u.lition of the patient are Hatisfaetory. the la- ..p.-n.-.l 
l.v an aiit.Tior incision similar to that deserilxHl. tl..- fia^-m.-nts 
ma.iipulat.-.l into i.ositi..ii an.l s.-. ureil by a plate or sutuml by mlver 
win- Th.- arm 1..- t.. tli.- to immobilise the J<«nt. 
Massa.'.- aii.l passiv.- iiiov.-ni.-iits an- n.iiiiii.-nc.-.l on tlic t.-iith day 
when the stitches an- ivmov.-.l. X.-.-.ll.-ss to say. a .an-ful .•o.isi.lera- 
tion of raai<.>!rams sli..i.l.l I..' ma.h- b.-for.- ..pcrativ.- ni.-asi.r.-s ar.- .l.-ci.l.-.i 
upon. R.'f.-r.-nce shouhl be made to the r.-maiks <.n p. on tin- 
a.lvantay.-s of i.-position over excision. , •„ i . 

Ill fiactui.-s ..f th.- ^ir.-at tub.-ro.sitv the small frajsment will be ilis- 
plac.'.l backwanls an.l n.tat.-.l while the shaft of the humeniii 
is rotate.1 Satisfa.torv union is v.-iv uiilik.-l.v t.. o.-.ur with 
splints or bv ti.xing the arm in a position of cxt.-rnal mtatioii. An 
incision should be made over the tuberosity which » then hxeU in 
position bv a .screw «»r pej;. , i «. 

Operative treatment o! leptration ol the npper epi»li»rie ol tbe 
humerus. This is oft.-n a .litlic ult lesion to treat. I iider certain cir- 
cuinsta,ic.-s op.-iativ.- ti.atiii.-iit. with the safety that modern pre- 
cautions, .lulv carried out. jriv.- nowa.lays. sliouM I..- ivsort.-.l [<>. We 
may divide the cas.'s that call for it int.. th.-}Z j.'ioiips : A. ( a.s.-s 
of simple iniurv. B. Cases of c.uiipoun.l iiijuiy. 

A. Sim/i/e.' These may be further divi.le l into : {„) 1 ot 
recent date, (fc) Those of 'longer standing. 

(.,) Si>,n,lr r</.v...v ../• sri^uvlHO, uf mn>t dot,: Here interference is 
iiustified when then- is v.-rv jrivat .liiii.-ulty in cff.-. tiiiji n'dnction owing 
to complete separation of tli.- tw.> ,.aits. ai.l.-.l l.v tlu- ivtation o tli.- 
epiphysis and the verv small .size of the upi-.-r liaf.'ni.-iit . Mr. I olan.l. 
in his "Traumatic Separation of Epiphyses" (p. •-'•.'(■.). stat.-s t.iat ..ii- 
of the chief difficulties in reduction occurs from the ii,serti..ii h.-tw.-.'n 
the fragments of hands of periosteum, fascia, or muscle, or fr*")' [''e 
penetration of th.- periosteal sh.-ath by the diaphyseal end. Other 
cases are those where, if the displaceiiR-iit is currected. there is much 
difficultv in maintaining the r.-(lucti..ii. when a sharp portion ot th.- 
lower fragment, having penetrated the deltoid. projecting under 
the skin, and where there is evidence of pressure the vessels and 

The operation should be performed on some such hnes as these 
An incision is made freely in the interval between the pectoral and 



tleltoiil: till' i-t'plmlii- viii w .Irawii' or tif<l Ix-twc.Mi (lmil>lf liya- 
tum. The •oft parts liiiviii« Im-.-h wi.l.'ly ii'tracti-d. the <'n.l> <.f tin- 
two fragments are next uU-iititii'd uml examiiiiMl. any n-nt in tlic 
mtonm Mng ran«fully pnlargtul if nmlful. It will in>w ho foimtl iMwaihli". 
ill .some ca^is. tn if'placc tin- fiayinents in ]«>siti«tn. and then, owing 
to the cniiiciil of the cpiplivsis. fixation l>y plate or wire will not 

h.' n.'.-.ssaiy. Tl l-_'<'s of lli'' r.'iif in tlu- |>»'riostfuni ami cufwule 

bhoiiM 1"' caivfullv siifiiiv.l. and it may l.r «.■!! at tin- Hanii- time to 
cios.' aiiv op.'nrd-up pfriarticiilar |)liinfs of connfctivc tissu.-. it may 
Im- neetlful, wlifii the fra};mt'nts cannot otlimvisf be hvou.'lit mio 
pwition. to remove aiiv jtioji-ction from the hiwer frapmnt. if tli. re 
is anv (liilidilty in retaining the fragments in position it will be best to 
will' tlii'iii tci},'i'tli(>r. 

In ili-iM' cases wlitT." the epiphysiM in not only s.-paratcd. but dis- 
locat.-d owiiiy t(. thf .s.ncritv of the injury liaviiii.' laccrat.-.l the c-apsule 
freely. Poland ' advises as follows: " Scciiij.' tliat it is almost impossible 
to reduce the head of the bone in these extremely rare cases, an incision 
should be made throu>;h the skin and (h-ltoid down to the seat ol s paia- 
tion, ami the epiphysis replacetl in position. It will be found necessary 
to open the capsule of the shouMer-joint before the epiphysis can 
|m' leduceil. This should lie accomplished by direct manipulation of 
the head into its place bv pressure of the thumb and linp'is. or by 
means of a traction hook inserted into a hole drilled in it after 
the methoil advcM-ated by McBunu-y. The fragments should then 
be fasteneti together in their normal position by means of pegs or 

(2) Cases of older date. Here, where some weeks or months have 

elapse.!, interference may be called for. owiiijr to the limitation »i move- 
ment. es])eciallv as re<:ards abdu. tion. elevation, ami rotation, brought 
about bv the overlappini: of the fniiriiicnts. tli'-ir iiiiioii in a faulty 
p)8ition. and the projectiiii; callus. Mere, after exposure of the seat 
of union, and free retraction of the soft parts, the siirizeon will have 
to follow the advice of M. Walther.- and then decide between 
the necessitv of conipletelv respctinn the callus in order to place 
the fraffiiieiits absolutely in [Misitiiin. or to freely remove any pro- 
jectiiif; ends of the diapliysial tniv'meiit. and plane away any e.xcessive 

B. ('(unii'iiinil (v/vc.v. Here resection of tiie ^irojectint; end of the 
diaphvsis will usiiaii\- lie required before reduction can be effected, 
a step that will facilitate the thorough cleansing of the parts which is 
so much required. Wiring with sufficiently stout wire, and suture of 
the rent in the perio.steuiii. will be re.iuired. as already indicated above. 
About a fortnight i.fter anv of these operations, passive movements 
should be begun, and perseveri.iglv continued, together with friction 
and massage. 

Arthrotomy of the ihoalder. 'i'his operation w^ill be indicated in 

cases of acute suppurative ."rtdritis. usually pvfemic in origin. 

Tn order lo avoid the d ndon of tin- hirepH .in iiirisioii should lie made for two 
inches iur<. !..■!,-« Ihr .ni.nuh.a. divirii::;: ! !:- i'^^l th' ii!.r."; of '.]■.:■ ,h\'.'M<i. Tho 

capHiile is tlien easily exposed and may be opened by a vt.tical cut. For cffittive 
' *«nr(j fi7.. p. 243. 

» Sev. (tbrthop,, Jan. 1897, p. 43, quoted by Poland, loe. lupra eit.. p. 240. 


rtniiiiap ,1 . iii. iM. M i- I. i l..«.^t nf II,.- r.i|.,iil.-. I!.iii:li,inl 

,i<lvis.« tiMl ilii:- '•li.Mil.l I . I . .-I.- 1^ fnll.m,: ■ Tlif Ik hI ,,l..ti M In r,.i«.> Hi.' unn 
al><i\c' till- I', id -> .1 t . i. ri l till- I" . Ill "f 111!' ImmrriiH iix [irtMiiim'nt in Ihc iisiiIm 
i.n».il.l.' mihI III. I, to . 111 il.'wii III.011 lliiM I'V nil im'ixMHi nlnwt twii iiw)t>-» hMiu 
i„si l,..l,.« tlir iiMllat v v.— Is. Th. M- Hr.' i.hiiliHr.1 Hiul | ii,« «. «« t» 

,.xiM.«. II iipxiili- lii li-w ati.l lK liiii.1. Tlx- Wmi «rf tiM- Ikhk- . all U- iii.mI«;"u» I.v iIm- 

finiPT in Um- iixill.i. niiwiil.' iniiy l"*' <>|--n<il »»>• nitliiiL' ilnwii ilint-lly ii|Hm llw 
Im'iuI oI thi' i lliiH inav U- fi>. ilitiif«il l>.v liriiiKiiiK tli.' iiriii ilown. and iiawiiii« a 
hms i»ir 111 .U. '4iii« fon i 'jw a. i..>s jiiint fnmi th»- u|>|i«t iiwwifm mul miikiiiii 
th« ir jmintii imijiiit U iwuni i li. . ii.hiI.. im» tbut «ln>> Pi»n In- cat ilown upon tiwl mmte 
to M>iic< tlH> ilminttgi' tiilH> uimI |>uII ii into |Mwi«i»m. ' 

( HAFl'EK X 


Indications. M) Xt'W }ir.,wth.. esp.H-iallv jlJ) -s ;n,.l 
■,.1 1 11 \(, i.lcnts. r..;. raiUvav aii.l iniicliiiifiy accKl.'iitN. 
; \s l / of tl.. al,ov.. is practk-allytluM.nly con.litH.n wh.eli 
..,11 or tho .vn.uval of tlw \,on.. an.l as these cases present the greatest 
dtllieuhies. it is t.. r-Mnuval of th- scapula for new growths that most 
of the foHowing remarks will apply. 

\ Partial Mmoval of the icapula. In a very f.;w casos (,■.-/. vM«'u 

tl./sM, .n. o,K.ratinji .m an exostosis, is uncertain as to t h. nature 

its ,asc an.l .Iocs ,v.t feel satisfied with goupnig this, or where he is 
■r .i. tint lie .lealin- witii a choiulroina and not with a chr.mdnfying 
, iV noval of the niav he sufficient. Canes or 

"•t 1 v,..v ran. .a., call for nu.e than a partud 

: The chief point, ii.rc arc: .1) To cx,h,sc livelv th'" fz- n h 

>v ., mrol.riatc Hans, so that the hinits may he clcailv .h'tn,.;,! . (.') o 
EK iviih reliable instruments ..f keen temper, own,, to the 
,.v,.,.,.,liic' hai.lness which niav he met with h.-iv. 

W l ie some continental writers have given elaborate dnvct ons 
for artial rciiK.val <.f the ... apula. it is only i.t the above few .-ases that 
lor P'«"'''' . ... , „^,„| i„. K.iirlisl, su.j;e(.ns, Mr. TolkK-k. 

nCmitwc s of removal of the scapula ' thus a.lvis.. on this 
. t??^-- 1 a portion. .^^ the .s. apula he .e.novcl. it shonM only be the 
portion Hut even if this be attempted^ the h,ss ot blood wouh 
, ,1 V be nmcl, .'leater than if the whole bone were removed: for 

^ i ,non.^..nli i- and the wounded arteries are more apt 

,.; rac l .h.nd the h above, and offer great obstacles to their 

eiiL However. >ho„ld the lower ai.'le be alone the seat of 
isZe the attempt to remove the lower portion onlv is ,|ust, lable 
I ,Tst however, be borne in mind that, when a bone ,s once th. .seat 
, i which requires removal, the di.sease is very apt to recur ni 
the po'ition left, anil is less liable to le-appar if the whole bone be 

'■'■"when in doubt as to partial or complete removal of the scapula for 

a cartilaginous tumour, th' surg > wiil be ehieflv gi.i-led bv t he dura t.jn 

^ndT rate .,f progress of the growtli. its deiisitv. how far it ^«t>Htl.^ 
and ^^hether there is any evi.lence of adjacent nodules of 
r« Dointinu lo an infection of the medulla. 

Kriv'a^nr,;:' 1;.,"::..;...'.' .,.„„., »h..,t .,,.,,,1,. ^ t»k™. -w 


oxtremitios being han.h.u.-.l in cotton wool, tiu- l.ra.l kopt '"W- "'"l 
the matoriaU for infusion in iva.iin.-ss. Tlio pationt is j) a.v.t at t i.- 
,.,1.'.' of th." tahl.' and roilwl over to tlu' opiM.s.t.' sul-. II tlu' growth 
is'v.TV vasiular. or th.- pationt weakly, pr.-.ssnre on the sn x lavian. 
if elVeetual. niav l.rlp : ..r if. from the .-xtension <)£ the growth, thm is 
,vn.hMv.l .liHi. ult. it n.av I.e ,'\Wwd l.y n.akinfi an incision <U.wn t« and 
thron-h the ,leep faseia ..v,t the ait.rv itself, in ..nler to enable an 
.-issistaut to put his thumb or lin-er .liieetly upon it. Iliis may )e 
(lone bv a separate incision, or by an extension oi tiiat hy nvIiic h ttie 
clavicle" is divided. Hut as movements of tlie limbs may easily dislod^'e 
the a.ssistant's finder, the operator will do better to trust to pl-;"1y J.'l foiveps and tviii- the vessels as they arc divided. Nr 
\V \Vat.son Ch.'vne re.oinin.Mids preliiiiinarv lifiaturc of the subscapular 
artery. This sui;;eon has made of a pieliiuinary anterior n.cision 
in the removal of the .scapula for a lai-e chondronm winch h led up the 
axilla, "proiecting the pectoialis foiwaids to a marked .le^'ive. an 
incision which he in all' • In the lust mstance an 
incision was made, beginning beh)w at the junction of the a.xillarv ami 
hiachial vessels, aiul iiiniiiMu' up in the line of the former, so that the 
axilla was freelv opened in its whole extent. The anterior fold of the 
axilla was raised so as to expose the eoia. oi.l pi..r,.ss : the three 
attached to this were next divi.led with l.lunt im. ted seissois kept close 
to the bone. This fullv e.xposes the axillary artery and its suliscapular 
branch is at ..nee ligature.l. The patient was then lu rued ov. r. and 
the oi)eration completed in the ordinary way. . . . I he ligature ot tne 
subseaimlar arterv r.nsweied a.lmiiablv. In this case the patient lost 
.■xtremelv litth- Mood. proi>al.iv not more than an ounce altogether. 
The (h-tachment of the musrles attacii..! to the coraeoid pr..cess also 
enabled the operation to be .■onipiet-'d very raj-Klly. lor alter the posterior 
scapular muscles had bwn divided, and the trap.-/.ius and the .leltoi.l 
had been raised, the acromio-davicular joint and the muscles g.jmg 
to the head of the humerus were practically the only things which ha<t 

to be di\ ided. . , . i r i i 1 

The pati..nt beiim turii. d ov, i tlaps are ,|iiu'kly and freely turned 
back, usuallv bv a T-shaped incision, one limb iniiimi<: the aciomio- 
clavicular joint inwards to the superior angle ol the scapula, while the 
other and longer is nuuh> at right angles to the first (h)wii to the a' gle 
of the scapula. In another case the surgeon may prefer to mak.- an 
incision alon.r the vertebral border of the scajuila. and th.' other at right 
angh-s to it a.'ioss the .•.■ntiv ol the L'rowth.- iKig. IKi). In either case 
care be taken not to open the c apsule of the tumour. 

tl.»ra< i.> a.n,...t.vtim.. J. .1. B.i.-l.i.nan. wl... ha. ,.,.„.i,l,.,...l fully tl.| . In. ,; 

partial an.l ..MnpK-tr t-Mmv.l uf tl„. s,.a,mU ar..l i.l. r.ra,,,,!.. tl.o, • ' 

/'/,//-,././,,/,/. .1/../. .h>'n.,.. I'.HMh. .,Ki-,.. that th- ,.i.t..m1 of ' 
IH't.-, vul i L>.-.1) I" fnll,,«,,l. • iM ,-v,-iy caM. m « hnh ,t is su^ih. tr.l t hal l.r. xi laiv 
v,..Jl- a,„l nn v. , >u:.v U- involv, ,! in a ..■n.wth of tl,.; ..•a|ml.i. the otH-ration s >.,., < U. - 
,„„,l.„t,-,l that it may. if .l.Mtahl.. 1.. .■o„v..rt..,H.,lo a fonnal ' 
ai.M.utaf io„. H.,. make- the {H.^t.-rior a.i.l . lav ,. ulav ..u is.o,, ..I M. , . ,1,^ i,l.> h, a t. 1^^ 
ni.. its „f th.. «...! f r..tiu'h this i,.. isi,m tnal-. s a .huMtal , va i. ..f H..- . la i 

f tl,.. s:r..«tl. t„ th,. v..s-, K and n. fv,.,. If ..t,-ia, t,.,y „.t. ., ,nat ,„n , a,n,.. h 

uai.,..d I. r..s,.,.ts tl Mt. r t 1 ..f tl„. , lau. 1... v.|.a,at... tl„ -.'''^VV;;;;, ' 

th..c.,.a-,.i.l. an.l thns ..ain- In lt. , a, , ,-- t., t!,,- ^. -.1- an.l n.TW ... I . 

1,0 s,if..r to f,.ll..w H.......f. a.,,1 in all t.. h...,,. w.fh "_''-^'^'''''Vil''7\™^^^^ 

"«**tf the hkiii is involved the must bo nhapoil m> as ti. ixitluU- thin. 


When the whole umss is tlioroufihiy exposed, the tnip«;zius an.l 
deltoid are first severed, the arm being pulleil away Ironi the trunk 
The levator anyuli scamilw and the rhomboids are next cut tluoujjli 
the „<.ste.i..i- s...pular arterv seeur.-.l. an.l the serratus magnus .l.vided 
l„.i„'r tirst nmde tens," l.v liftinfi the scapula off the ribs upwanls and 
outwards. The nuiseles on the upper imrd..r are now dealt with viz. 
anv remains of the .leltoid. the ..uM-hyoid. an.l the supra-spnmtus-- 
and the supra-.s.apular artery seeure.l. The aeronuo-.-lavieular joint is 
next oiMMied, or else the aeroiuion or clavicle, according to the e.xtension 
of the growth in this direction, severed l.y hone forcei« or a narrow 

saw. If the acromion can be salely 
I left, the resulting deformity viz. 

,ln,ppin« of the shoulder and entire 
loss of the action of the trapezius— 
will be lessened. 

The lower angle being freed and 
the lati.s.siniiis dorsi (if involved) 
resected, the .scapula can now be 
dniagecl awuy from the chest by slip- 
])ini;'^two or' three fingers over the 
ii|.l«'r or vertebral border. Thus, 
hv tilting tiie scapula outwards, the 
anillarv border can l)e inspeeted. the 
teres and infra-spinatus muscles 
severed, the position of the sub- 
scapular artery defined by a finger 
])assed beneath it, and care taken 
that this ves.sel. already tied through 
tiie ]»i('limiiiarv incision, reiimiiis 
safelv secured. The scapula being 
still further jmlled away from the 
chest, the muscles attached to the 
coracoid process will be seen sevi-red. 
F.O. lncisi„nro, . x. isicn and the scapula is removetl by cut- 
ofth. >.atMila. ting into the shoulder jomt and 
•severing the ca])sule and th;- tendons 
of the biceps and triceps. The coracoid process may becoive detached 
at this sta-e if partiallv eroded bv extension (.f the growth. <.r i tlie 
patient be'young. If this happens it must be carefully .assected out 

afterwards.- , ... 

The different arteries, besides the subscapular, must be secuietl U 

I It is a l>a«l siiin if any of the mu«i I<'.-< st virwl are iiifiltratiHl witli (.'r.iwtli. •rhat 
this 1 ' not in<-nm,» with a rchhI recovery U. however, shown by the OHse quottnl on 

^' 'f'if tlH. ruvstl. has i,u„Iv...l tho axillary voHsels and nervoH. this outlyins i...r|ion 
m vv l.e .l.>air«ilh Utvr on. afl. i' the main nm»« has lK-..n seiwratcl an.l n'movnl. If it 
"s (UrtK to r^^^^^ thi.s exten^io„ „f . hr -lis-ase no* while in cnlnnnty with he s, «,mUr 
^r «T itself ?he s,.r,.eon will l.u.- I.nth his free for what H a <-ml,l..s,,„>,. ,1,.- 
ti.. l.v akinu an a->i-taot t„ ,\ux^ ihr main nm^s st.oni;lv .a. Hut it will 
, w . 1 nc .se- wh.L. ih. n. is ..v„h ,h ..f .Im' s.a,,„!ar ..-wlh hav,,,,' enen«ch..l umn 
„. Y. ;.. V.U..1S an.l n..rv..s. I., ol.tain l.^av.. f..r the ,K.rf.,r«.an. .■ ..f an .nter-seapulo 
I , .,.„.,....,,;„„ Th" first sl. i. in the ojKration shoilW n..w be divisK.. an.l siifiieient 
renio'val of tli.- . iavi.l.^. so as to i.p the «tat« of the above i.n|K,rtant 
If thl-y an- involvMl by tho gr..w»l. the more extensive olMTation HhoulU at oneo b« resorted 


possible before they are rut. T..<> n.any Spenrer-Wel!. J-'^^'T^ 
K,t be left in at oue time, ..r they w,l be found o .nterfe.e t h he 
needful manipulatiou of the bone. Every vessel .must »»y^"^f^'y 
secured by ligature ; otherwise ooang a liable to occur a few hours 

Himiorrha.'e nuiv be best avoided by attention to tlie following 
points : ( I ) Makin- use of Sir W. Watson ('l.eyuc s method and sm.nn« 
he subscapular a-^terv early. ( >) Where tins method .s « ^ «' 
a trial of Adequate pressure on the subc avm... tins ' " \ > 

a special iiK-ision. if needful, to eouunand t^ - vess.-l. ReaM o « 't 
tmSting to this have been given at p. 22^. (^) Deahn, ; ' , . 
bonier and s,„p„lar artery last. (4) In any case rapid « ; " 
„r seissors l,v the operator, ai.led by intelligent help from asM.tant.s . 
seeurin.' bleedin.r-points. and f.on, '>"'«'«*»''' ^V'^'^f ^ 

undulv anxious, is essential. ..-.) Tak.n. earc not ^^^^^ '^J;^^ 
growth itself. (.;) lU- ,son,e ,t ,> re. on.m. nded to n.ake » 3' 
graduallv. n..t larger than are re,,uwed at the tune as a n.eans 
mi.unusing the hiemorrhage. It nmst be re.neml.eve.l. with ' 
;!,is point, that small and eramped mcimons mterlere with a n ,1 
rai.i.l hand an.l sutlicient exposure of the prt«. conditions ^vhu 1. on- 

duV.- t.. thorough .lealing wiili LI ling-lMuntH, and thus facmg one ol 

the chief dilfieuhies of this i.niM.rtant operation. i:.,»,ilitv to 

Adeciuate drainage is now provided o„ aee. nnt ''^ J 
subsequent oozing, the atta.'hments of the trapezius an<l deltoi.l sut . 
?;igether with fini sterilized silk, the flaps unite. . an.l the arm seen . 
to the side for a few days, after which it may be supported m .i shiig 
if th.' head of the humerus does not tend topr«tj-ude. 

The mali-manev of these sar. omata is well known.' togeth.-r vuth 
their ten,len<;- to involve surrounding ,.arts and to creep regums 
i.uiceessil.le to the surg.-on. Karly operation ,s imperativ- y '■'"l" '•<^' • 

In the case of operation, the prognosis will be bes^ h-wpe. 1, g 
the growth, when the lute ..f progrm has ^ 
is u.dformlv hard, or if only a certain amount of elastic.^ 1^ o 
with the har.lness. when the outline is distinct and wel! defim'd. ami the 
mass movable upon the ribs.* 

n'rtai..,, va^ nrUvinrut liK.-,.s. rt una- .liimrs nous a, . i ■ t ' 
L.mvnuU ,,1... ...a. a la m.V,;,,,,.,,. ,,,>.• la '-'"'X . ; ' ' ' ,t' ^ 

.(xilUrv r uf o,... : ', 

sliuhtlv w!i. tlm arm an,l scapula wen- raised at » ''' I" '' ' t lu in t 

,,i;ura- W.-.V f..und t.. b. I.le„a.d with ll.o growth \" «••';■ ' '^ la ■ t u U dav. 

The MH^imen which iHu»traU-« lhi« iiwlmctjve ca-sc wtB be fmmX w th« HnMman 

tion, kt'.s.. N«.. rmn. 


On the other liaiul. tlie profjimsis is less favournbl.' vvh.-n tl..' oullino 
is uniform ratlu-r tlu.i. lUHlulatod ..r b...ssc.i tlio fo.-l sonn-. lastic 
of harl. the profin-ss rapid and painful, the ditt.'rent parts of the s. apuUi 
much ..l..s, u.e.l and its ni..hility nnuh impaired the outlme of the 
growth ill (ietiiied and in.listi.utly in the axilla. Pulsation, bruit, 
enlarced ulat.ds. intiltrati..i. ..f tli.- skin, an.l any local rise ni tempera- 
ture are also of evil omen. In these cases, when the pr..jin..sis is un- 
favourable, the surgeon will do well to resort to mterscapulo-thoracic 

'^'"Caition o! the Umb after removal ol the scapula. .\ limb thns 
pr.>serve.l will he stronfr and useful. If the clavicle has not been much 
interfered with, the .laviculai fibres of the deltoid will remain, and 
these, especially if snture.l to M.e trape/.ius. tujrether with the latissimus 
dorsi and pectoralis major, v ,11 probably confer a fair amount '""Y- 
ment on the limb. In one of I'n.fes.sor Svn.e .scas.-s. after renu.val o th. 
scapula and the outer third ot H.e clavicle and. by a pre^ous operation, 
the head of the humerus, the patient was able to lift heavy weights, 
ami to till *he appointment of provincial letter-carner. 

In a verv siicc-ssful case of Mr. Synionds,' in which the scapula 
was removed for osteosarcoma, the man was in good health two years 
and a half after the operation. 

H,. WHS al.le to do al! tl..' li^l.t work ..f a ear|H.uter. inehuling the " I'J""*'- 

Ov. rluad work lie coi.l.l not <lo. b. this eu«- the art.cukr surfuce of the humerus 
lid lo beou niuoved about a mouth later, as it was thought to bo the cauHe of 
prolonged suppuration. 

The followinj; case is of interest from the extension of the sarcoma 
into one of the scapular muscles, the ill-defined outline an.l soft feel 
of the t;rowtli, its long duration, and yet the long period of relief which 
has followed : 

IuMar.1. \m of the nurses at the Canterburv; Hos,.ital was sent to Mr. 
Ja, ohs,! b V Dr. Alexander of Faversham The out llj... of the ^^''-V^ ^ 
replaced bv a large mass, of uniform outline, fairlv d. tmed over the lo«er two- 
fa rd^ of the bo^, but above very indistinet. senn-.-lastie to the f.e without a,.y 
noS^or bosWof harder arowth. The sca,mla was movable u,.o.i tlie ribs. J hi- 
"^^Z^^^Xfor^m months. N.r the las, t.nv.. n.onths the 
in th7si«e of the swelHug ami in the pan. ha.l, ahke. b.., n ra .„ - '.'I^ 

was iv-moved in (iuv's Hospital. The most mlrn strnn i-mi al oat i he «.is 

sare. ma. whieh appeared to have l„ «un in th. ,ufraspmo,: < f"-^ 
p^lratedthe bone, and in many plaees yish n.ass.s of growth ^ff'i 
CdiiVir with and n pla( in« the .h fas.i.ub of the Md..sea|mlanB. The chief 
.TiC V met wi 1 in' was k.eping the alien, qUK-t Thew^und 
d I ot" run an as. p, ie eours... T. .. .lays later, incisions were required for dra nnge 
th. M. "! . ion 'which f..llowed. l.ater on. the art cu lar and e,,,,.hys^^» 
f the lu'a.'l an.l tub-Tosities of the humerus became d.>tach. d. J^'^'^'^^f^"^ 
„,H.ration ,h.- a,„ero.,««terior movements of the "houkler- . m, e 
The patient could nurse a delicate mother, use her needle. &< •■ > at ab.luction auU 
elevaC were almost atoli.hed. In s,,„e of ■ of one at 
U.ast of muscles, then- was no evi.lenc' whatever of any r.vurr. e,. e. 

Age of the patient. The scapula has b.-.-n successfully removed for 
growth at ase? varying betw.-en •• about .s.'venty a,.. ■ ub....t oif-ht. 
the former was a patient of Pr..fes8..r Syme who dietl about two months 
after the operation, apparently of internal deposits. The Utter case 
> Ctin. Sot. Trum., vol xx, p. 24. 

elevatore. ^ ^ j,^^^^ ^ 244. 




This <.p.Mati..... i)cif<.rn.oa cl.ioHy f..r {in.wtl.s of the humerus which 
cannot be cinpletelv ivnmved by airputati.m at the sluniMer jo.nt.- 
occasionally for growths «f tlie scapuhi. an.l lor those of the a.xi la 
as in Mr. Stanley Bovcl's case {see p. 237). Mon- rare y .t n.ay be eall.;.! 
for in cases of injury, for persistent carcinoma of the breast (st'V p 
for tuberculous disease, or for spreading; fjangrene. It has been aiUo- 
eate,! an.l described by M. Paul iiev-er. l>y name it is commonly 
distinguished^ aiiKHigst continental sur^reons. and by Sir F. Treves and 
others in this country and America. The method described behnv is 
that of M. Berger; a very clear account is also given by M. *arabeut, 
by Sir F. Treves,* and by Professor Kocher. These have been largely 

con^Uttd.^ Division of the clavicle and securing the vessels. The 
patient beini? broufiht to the ed^e of the table, with his shoulders raised, 
the surgeon, standing outside the lind.. makes an incision with a stout 
scalpel along the whole lenjitii of tl,e clavicle, from just outside the 
sterno-mastoid to a point immediately beyond the acromio-claviciilar 
ioint. The incision divides the periosteum down to the bone over the 
middle of the clavicle. At this stage venous oozing from the large 
superficial veins here met with mav be very free. With a curved elevator 
the periosteum is separated from tlie middle portion of the clavicle.' 
A large blunt hook or a blunt dissector beinj; pas.sed under the inner 
end of the bared part of the clavicle, this is divided with a narrow saw. 
The outer part of the clavicle being now raised and steadied with lion- 
forceps, and the periosteum completely separated from its under surface, 

t r»r Norman B. Carso.i has i-ubli^hod {A„„ of S„n, . lilia. vol. Ixvii, p. 796) an 

intpr..«tini' DiUMT on this .sul>ici't f-iviiit! ili tails i.f ii iiiiinl.. r- (if ( uses. 

,1 ,„l,t a« to th,. .»-,., V of «ul.>niUinK bis pati-.t to m. svv. n. an -'l'''>f 7"' *''°"'''„^" 
I V at! incision l„ tw, , n tl.o deltoid ami the pectoral. » major, am then, when tho 
muse los ar,. thoroufihlv retraeteU, examine the condit.on of tho nx.lla, theglan U. and 
dctermU the extent -..f the growth and whether the lar^;.- vessel, and ner^es a e 
invTT Inothereases division and partial ren.oval of tl,.- . laviele may U- re.,u. e 
Cr ta the doubtful point. In every ease this p,..|nnn,ary nu ision shou . U- made at 
thTtimewhen the o,a.' ation is to he . ompl. ted not as a prel.mnmry s ep. On thu, 
piint s paper by Dr. Tobb. of llostou (Ann.oJ S,.r,,.. I^ebruary liH..,. , . .'..< ). 

» PwUminary detaehn.ent .,f periosteum was reeonunen.led by M. Oilier as 'Y'''f;'F'"J^ 
««inrt wounding the vessels. 1 1'. however, obseun s the snbrlavni. an,l has to l'^ -l^v.ded 
J^diatoly. In addition in malignant diseaw it may favour neurrenee of the growth. 


the bone « aijain .UvicU.l «t tlio ..ut.'r cul of its nmWU. third. If re- 
iJ^ryparfof th. davicl.. is ,orfo.nK-a. tlu- nMuoval of 1....... nm 

fr... enoufih t.. facilitate the finding of tho suh. avian ^''f . " ' 
rnnoval l.onc will much incroaH.- the ^j^" ' , ; 

T , ten.l.-ncv <.f tlie xivv^-r .'xtretnity to fall outwards aftvr .hNision 
' ' daS- in„v,li. tl... spa... if tweon the P-^J^ ^Ij^ 
Tl... ..vnos,Ml suLclaviiis with its shoatli is now isolated and cut tnrougn 

Z:TS.^. of tl... i.n....- s....,ion o.^ th.. cl^mdo. J^-^^'d - a 

to PXDOse the laru.' v.>ss.> s. an.l tnrn.'.l ..nt wards."" "l Nar>ni^ 
Si'C w 11 ' t.. be divided In-foro the v.-ssels are r.;a.- ....1. Pnm^ 

is st^^.Tt 1.1 irreat ...H toral should be freely divid.^!. espec ially J^^' 
s l ie • I a 1.1 tl... 1 pper border of the p.-. to.alis minor if 
be 1. in.-d tb> s..V,'.'..n must be pL.^ar..! for troublesome bleedmg 
fr..i tlu. Vepl v.:in a.ul braiuhes of the arronno-thoracc vessda 
^:^*he mav find a gui.le ,.....on.,n..ii.l...l bv He..- y,. the x e;;] 

anterior thoracic nerv.- .asy t.. s.v or .-..I. 1'^ T W 

upwards, leads to the interval ' , ' 

large vessels are then secured and divided ^H^.m n .1 il i. 1..^.^. * «. 
ni.shed well aimit in each case an.l tie.l siHiurely befor.- the is 
t Tl e i vs sh..iil.l be pla.....l up..n the subclavian v.'ss.-ls 

sehvs a a p int t.. which tl..! tub.'rel.. .... the first nb wdl be a gnu le 

The ar m- Ihonld be secn.v.l first, an.l the arm well raised while the 
1 It^^e^L pkced ar.mnd the vein. s.. that as litt e bl.....l as p..8S.ble 

KiTL^S/Sctremity. Tying th.- artery ^ 
the vein and render the securing of it dith. nlt fnitli. iinor. . as 
P,1J J<.unn Pn.fessor Keen, if the vein be injure.l. aJiapp..n.Hl in 
h c e whil.' it is being tied, the wound will not be flotHled ^.th bloc d. 
I hoi^ver the v..i,. b.- s.. nui. h .listende.l as to obscure the artery 
tL fonner ves el must b.- taken first. In either case the greatest care 
m^s Ttkr;! t.> injure this v.-ssel f..r fear ..f air ''"t;'";;*; .^^^^ 
culation If any such accicient occurs, the sp..t n.ust .e nstantlv dosed 
and t^ wold flooded with sterile saline soluti..n. W ule exposing he 
sXhvirv.-ssels. the supra-scapular artery and vein will probably 
be seen c tlu> upper part of the wound and should be secured 
The e ve eonk sh..uld lie . .it s.piare an.l as high up as P«««'W«; 
they are severe.l each should be in,i.^ct.>d wjt^ novocain ""f**"* 
cSiiy against sho. k. Mr. 8tanl..v B..V.1 in bis . as.- iv, r nifra) finding 
?h?t remm'a of he inner third ..f the claviele was iusulU. ient to permit o 
eas - i ure of t^^ vein, whieh lay beneath tl..- .nn..r third remove, 
a?^ tl . r S from the bone. He also found that division of most of 
r bracSal plexus facilitated ligature of the artery, the plexu. at 
once starting into r.-lief on .livisi..n ..f the clavicle. 

Dr. Le Cento, of Philadelphia.- r<^^-'^;^:£^(:::;:;ftl^^ 
of the clavicle as pn- rrable t.. , , i isar i....hUi.m ho believes to 

he s.mpU.r. .iiii..k..|-. aii. sat r. h\ M\ mf- ; , . , 'i^d to Us miil.lle. an.l then 
incision is hmm ..v.-r th- ^ , '"^^^^^ ...rtiriul fus. ia are 

ourvc-.! .l..wnwanls to the a>. .....r '"^ J the cb»v . The ho.ic is then 

1 rho Mriu. mu»t be thor.M.gWy divided i,» order to obt*ln room for .*c»r.«g 

""'s"Ft.oli..K f..r th>. imlwticm of the artery will be «n.Aher guide. 
' Ann. ofSuri/.. Si-ptenilier 1889. 


now pulltd iipwuKls anil outw^nK and the nuliclaviiM Htri|i|«Hl of! or dividt-d. and 
the vi'swls thus well cxiHisi'd.' 

NrtWirf .itiiije. Formation of tlic (laps. I licsc an- pcctoin-iixilhirv 
ai»d cervico-scapular. and in fonninf,' tht-ni thi- siir;;con must l.f ^'iikI.mI 
by the oxtotit of the diwaHe. Tin- patient Ix-iii^ so phucil ami st. aduMl 
that till- whol.' nf the scapular region is free of the tabk>. anil the 

Mun 1 standiii}.' to the inner sitle. i.e. between the limb and the trunk. 

the" I)eftor«>-axilJary Hap is cut as iiidieatcd in Fig. 117. As there 

Fio 117 lntiTsc.->i)iilo.tlii>ni( i.' anipiital ion. Oiitlm.^ of the flaps (leftside). 
The postiTior or ic i vi( apular 11. p is n .lutti.l. (laralKMif.) 

shown, it conmietices at the middle of the in( isioii over the tlavitle 
runs downwards and outwards just above the eoiacoid proeess, and 
then parallel with, hut a little ..xternal to. the dei)ression between the 
deltoid and the pectoralis major. On reachin<: the point where the 
anterior fold of the axilla and the arm join, the knife is earned over 
the lower edge of the pectoralis major across the axillary asjHHt ol tiie 
arm (Fig. 117). and then backwards and downwards (the limb l)em<; 
well raised bv an assistant) so as to pass over the lower .'dtres of the 
latissimus doirsi and teres major and end over the apex of the scainila 
iFii' 117). The above incision onlv divides skm and fascia". Ihe 
pei^oialis maior is next cut. and the pectoralis minor found and severed 
near the coiacoid jMocess. The top of tli.' axilla bein;: now well .)])ened 
up, the cords of the plexus, if not already severed, are .livide.l at the 
same level as the great vessels, great care being taken of the ('entml 
ligatures on these, the patient being n.lle.! over on to his sound side. 

iin.pli tc loiiicival of the hone i-* .--afcr in <'asc.< of 
,«th than leavniu in,, .-u inai nio. l liis would also l)e indicated where there 
arc Kfuat difficulties in lin.ling thu mibtlavian arti ry where the clavicle itBelf ix involved. 
In the hitter case, however, it may be questioned whether any operation is advisable. 

1 Dr. Ia' Conte also jHiints oiil that 
j^rowth than leaving tln^ stdnal eiiil. 


nn.l th.' liml. .lii.wn m( tlir .In'st. Th.> .• flap is now 
made l.v .In.wiii- tli.' knil.' In.m tli." oiit.T «-xtr.'niilv "I tli.- rlaviculi.r 
incision: struifil.f l.a< k uvr tli.- spin.- ..f tli." t.. tl..- Iow.t ai.>.'l.- 
of this iM)m>. wlu'iv it inwts tli.- liist incision. M i- sk... an.l las. ia 
aivi(lo.l by this incision an« rctlc<tc«l to th.- vcit.-»>ral l.oi.l. r <.l tli- 

scapula. . . . .1 1 

\..tlilii.' iiMW ivinains Imt tlic third ami hixt sUufe. viz. the mnovul 
of tiic lin.k This is clTc tcl l.v tlic -livision of th.- trapznis. omohvoiU. 
latissimns doisi. l.-vatm- aii).'uli, . Iioiiilioiils. and sci iatiis nia-xniis. W hllc 
tht«e nniscU-s un- scvcivd the (laps arc well held hack and the hm») 
suitably nmnipulatwl. partly by an assistant and partly by the mi 
hand of the oi)crator. , 

Dm in.' this stajr<- the posterior scapular and the supra-scapular 
,nav or mav not re.|uir.> li^'atures. accordin}! as they spring from the or the thinl part of the s.d.chivian. in the latter case U-nip on the 
distal side of the ligature (Spencer). Hnt. of course, the mere nu-ntion 
of normal arteries pves no i.lea of the mimher ol l".th veins an.i artei-ies 
that will be met with, enlarjjed. in < as."s ol new iirowths. I Ins makes 
it all the more important to w-cure first the subclavian art.-i y and vein. 

The flaps an<l all the recesses of the large wound are most careful y 
scrutinized for anv evidence of infiltration or extension of new prowth. 
The muscles, especiallv th." pectorals, shoul.l be cut short to av.nd any 
no.ssil.ilitv of inliltratioii. Wli.'re it is tliou-ht a.lvisal.le t.. shorten 
the n.' .Mch ..f tli.-s.- should ajrain be inj.rt.'d with eucame 
(.s.r p 2:5.-.). Th.- c<m.liti..n ..f th.- > in th.-'n..r triangle 
should also be investifiated. Drainaffe sh..ul.l always b.- .-mpl..y."d on 
account of the subseciuent oozing. 

Mr. Ktanley Boyd' has reputed the following mstrii. tiv.' cas.- : 

Five w.. l;s ,,r, vi...islv a m:.... :. t. -V. Im.l ...i.l. r his <■,,.;.• M li.e rW-yvuv- 

(W Hospital for .s.nM.n.a ..f \W axilla, whi. l. l-a.l altai.,..! tl.c s,/.- ..f t«,. liMs m 
three mouths. It was not lis.. I lo l"-..''. I'.it was .■l„ atta.-h-.l t.. son..- .M.ft 
„arts. Th.T.- was no . n i.l. nr.- <,f ,.n ss,>.v on I he L'n al v. s.s,.ls „r ... rv.-s. of uivolv. - 
„..nt ..f th.- s.ipra . lavi.-.ilar ..r of s.., o„.laiy -.-owths lu th.. vi«oi-ni. 
l),„-iali..n 1..-..V. .1 that th,- «n at vess.-ls an.l n. rv.-s w.-..- «. surro.ind.HJ hv Rmwth 
that ...ilv an int.-rs. a,...l..-thoi-ari,- ani|.iitati.m W...1I.I i-.-in.>vo tlie clis.-iis.-. As ton- 
s, nt ha.i n..l l"-.-n olitain.-.l. n..thin^' further was iloiu- th.-n. Bour w.-.-ks I .l.-r tti.- 
mass thi- ha.l iM. r. as.-.l considenibly. nml am|mtatiou was p. 1 .ii^m.-.l 
„n I!, .c.-r s liu.-s. with certain improvements in two or thrtn. details, wlu.-li liave 
1,,-. n m. ntiou.-<t ahoy.-. Tlio patient, at the time .if the n-port. wos making an 
rxccll.-nt r.'.-.)v.-rv. 

Dangers ol the operation and causes of death. 1 h.-se ar.- : 
(1) H(rnwrrhnqc.^ This niav be m.-t with fr..m the mam trunk, the 
scaiiular braii. h.-s of tli.- sub. lavian, the branches of tlie axillary, and 
the .-nlar<i.'.l anastomizinj; v.-ins in cases of growth. The first two of 

> 7ir!/. .l/r</../nHr».. vol. 1. ISOS. p. ss:l. ,„ . , i.„f 

= Cml.-,.! of this i.s the k.-v to the Mt.iati.a.. The« cfts.M sl...» what difh- 
iiilti.-s ,nav 1..- ..i, t with in meeting it. Mr. Maonamara {l.nnr.l. vok !>• "'• !• 

,;ft,.r ..•s..< -tintr part of the claviHe. was unaWr to find the art.-ry .mini: o the lart'e x - ...s 
expos.-,!. The ha-m,.rrhaLM- was v,-ry ur.-at. an.l th,- pati,-nt . ,,-,1 on th- fo!l,.w,ni. .lay. 
A pati.a, of .n.wth was foun,l to have pass,.,l npwanU l., l,m,l the -.;;'':;<' ■""^" '/'^ 
Prof. K.-.-n (.lm,r. .lonr,,. Mnl. Sri.. .luno lS.t4) .n, t with t:n-at tm.i '1.- m s..ourm,i; the 
Miholavian v. in. " .\ larL',- vein ..n,l,-r th- i,.n.-r sawn .-n.l of the clavicle tore, and gave 
„.h„.„>hl.-. bnt tinally. partly hy a l>«at,.re the tis»ue8 n which lay the vein 
an.l partlv hv a lipatnr.. which wa« applied teuiporarUy round the ti^ues »«-» w«nd the 
«awn ciHl of the clavicl.- in .i groove sawclin the bone, m a.- to prevent the slipping of the 
ligature, I w»« able to control it." ,o _ t..„_ibi»i 

Another mort InrtrucUve caw fa given by Pwrf. Keen (Attn, of Surg.. June 1805), 


those .langers a.ul tin- thir.l. t.. a hw ••xt-'!- ^i'S.?;! 
.ubclavian v.>>«.-l8 nftor n..-tlu..l. 'I'lnH also ,.rovent« entrance 
S a ? into tho larp. veins. ..f se. ti.m ... va.s. ular .nus.-le« 1 ke 
great pectoral with m nm ly any M.-cjlinj!. i^"*""' 'l^-*'';! 

pLtorior lAusclea, where the arterial supply haa not been cut off, la 
reserved for the last atep of the operation. 

If after resection o1 the clavicle, it ia found irapoaaibte to aecure 
th.' thir.1 ,.art of the subclavian vessels owinp to the V^^^ 

,M./.ini;. or to the displa. .ent ..f the ,.arts from invasion of the growth. 

Sir F T. Chavasse a.lvises pro. ee.linv at once to make the upper part 
of the anterior Hap, divi.linj: the two pectoral muscles aiul. " f">Jy 
expwing the first part of the axillary vessels, traeinjr these up t h. 
scalemis anticus and tying the subclavian artery .•"^ 
courses open arc to tie the subclavian vessels in their par in the usual 
wav If all tlu- precautions described above be taken, the amount of 
blood lost will be very small. Professor Koeher' says : 

•We performed this o,KT.Uion in HHKI a Im.v for a diffuHe -^'^^^'^^'iH;:; 

Onlv two teMpoonfuls of l.locxl were lost, and m tivr dav.'^ tii ■ «■ . "; •' ■•' ' > 
c«ve,^^ir»'^p of collodion, a 

through a special opening in the postenor fold of the axilla. 

,21 Shock: This will be met bv taking every step t prevent shock 
and ha-morrhage. ba.ulafrin^; the lind.s and abdomen, keepm- the bodv 
warm on a hot-water table, administer,..' ether. emptvm4the 1 nd. 
of venous blood before the vein is tied, and compU'tmt; the operation 
as speedilv as po.ssible. Afterwards, infusion of saline Huul ^l'-'"'' ' ^ 
resorted to. while subcutaneous injection of strvchniiie. ether, "™ 
enemata of port wine and beef-tea. and bandapng of the other limbs 
mav also be eniploved. . . • j i... 

This will b.. a fitting place to ref< r to an important point raised by 
Harvev Cushi - in the avoidance ..f shock in major amputations In 
cocainization ot large nerve-trunks preliminary to their division as lust 
advised by Crile.' "The term 'shock' represents a peculiar stati ot 
depression of the central nervous system. Such a condition is usually 
brought ab..ut hv injurv of one sort or another to peripheral afferent 
nerves, the impulses from the injurv haviiif; acted rettexly upon the 
vaso-motor mechanism in the medulla, so as ^"/auso a marked fall 
in the blood-pressure. While shock may be dimmished bv perfect 
hsmostasis and preventing chills, in cases whe.r shock i.s already present 
before operation the possibility of prolonged amvsthesia and son . 
further los,s of blood render it certain that a further especial risk is 
attentlant upon the division of important sensory nerve-trunks. As 
Sue injeeU-d into a nerve-trunk effectually blocks the transmission 
of all centripetal or sensorv impulses, cocaimzatmn of mam nerve- 
trunks central to the proposed site of their .livision in a major amputa- 
tion prevents the conduction of those impulses iroinJ\,.H 
further injury, which otherwise, bvactin;; reHoxIy throu<rli the medullary 
centre, might become further factors in the production of shock. 

In iUuHlratiou of the ahovr ,,ri... i,-l.-. ru.l.ins r. !:..... two '^^l^ 
thoracic amputation, one of M was .lone wuhout. the o her with ^' [^^^1^''^^^ 
the chief nerve-trunks. In Loth hu-mostasis was coniplote. and. except for tne 

» Oper. Su,g.. p. 382. = I "«• "/ 'l^"'"?;. ^^'^'^"'Y' 

• PrMem.'. RdatingtoSurgicalOjKralionsJVnladdphiu. 1891. 


«l«v.. .lillon ix T ill o,HTtttive tc-chniqoc. the «nmmi wrn; in rv. rv iv-.|»-. t >ii".l.i.-. 
Two ch»rt« n<conling th« uoLw-rntv btp glv«ii. ahowinx ili»lin. ilv Hint m tlif iii 
which the rn'rvvtrunk" wore di\'idiHl withfMil (<tM>niniy.iiti«ii «h. n- w>\* innrkpri evidrmw 
of Bhot-k. whii h wiw nlwnt in the caae wht-n- r.x iiiiir wa« . imi'I'ivi'.I. 

Liiml ' r>-liitr» a ctw "f tlio aliovc 0|i»Taliim f.T sanoni.i ..f tin- lini. liiiil |.h-xiis, diitinnloiin injury ami ..riKinutiim in Hi.- niiMlmn nrrv.-. in whi. li v>wh .oril 
ht tho I'.riioliiiil pU-xUH was iiijeit. .1 willi I. n minims of a t>-2fl JiW C««t. mttutlim of 
OMainf In fori- ilivision. The- \mW wan uiwlUct»cl. 

Ci) Si'iilicfimlii. Tliis is a vrrv probable dangor, if the flaps (iM'rhttiw 
li'ft nc.-illcssly full) sli.u^li. or if ivt.-iitii.ii and l.aj.'f.'iii'* of <li8fliarm'« 
arc allowed to occur in tlic largo cavity which will lie present in. the 
stump, unless thi* i» obliterated by preasttre, or sufiictent drainage 

employed. i t » i • 

(4) Bntraiiee of iiir into veitia. Thw very nearly prov( d fatal in a 
ease in wlii( h Mr. Jessop. some years a^o. removed the staptda, outer 
half of the clavicle, anil the upiH>r extremity.* 

In thU caw the »oa|>ula w-cnis to have lieeii r. iiiovi d cm inn "I" <oii»i(leialile 
doticiency of cover " after removal of an upixT limli mm li .l.ima«e.l l.y a inaehnier>' 
neeideilt. "Whilst entlinu lliroiigli iIm- lil^t atla. Iimnil- of lli. H<a|iula. two dm- 
tinet loud whiffs were heard, causeil by the rush of air nilo the HulKlaviaii yeni. 
The oin ration was eomfdeted white artiticial n«|»ir»tion ' w«h being periunaed. awl 
the lad recoveri'd. 

(5) Recurrence. While the results of this severe operation arc, as 
far as immediate recovery goes, good, recurrence, in the case of perioat««l 
sarcomata, takes place, as a rule, within six or twelve months. Hir V. 
Treves * writes on th point: • .\Ithou<;h interscapulo-thoracic am- 
putation is probably tlit best nu asine in all cases of sarcoma (os-sifying 
or not) of the upper part of the humerus, the juoiinosis is very j^loomv. 
In at least 75 per cent, fatal recurrence has followed within a year." 
The statistics collected for M. Her-jer show that the prognosis is 
better in cases of sarcoma of the humerus than in those where the 
Urowth affects the scapula or the soft parts, and that it is best of all in 

((i) If the patient survive, an artiticial hmb should be htted at an 
early date. It may not admit of active usefulness, but it will be ()f 
service in preveiitin;.' the feelin;; of most irksome lopsidednes.s which 
in the convalescence and early fiettins about causes these patients so 
much discomfort in balancing themselves. 

(7) With re^rard t<» the mortality of the operation, some recent 
statistii s are those collected bv MM. "Jeanbrau and Riche for M. Berger 
and brouuht bv him before the Society of Surpjery of Paris.* It will be 
seen that^ it varies widely accordinf; to the orijiin of the trrowth. In 
cases of growth of the humerus the mortality is stated to iiave been 
2-75 per cent. : in growth of the scapula L'.$-H<» per cent. ; and in growths 
of less certain origin. (■.</. soft parts, ^daiuls. &c.. 1 1-7G per cent. 

« linMnit Mi d. and Siinj. .Jniirn., April 1(1, UKKJ. 

2 Bn/. .V'</.J'oi/r».. 1874. vol. i, p. 12. - . 

» Unless the wound is kept flooded, this step is not without risk of drawing in more 

« Op^r.-Sm^.. 2nd ed., vol. i, p. 381. 

' » BvU. ft Mem.. May 16, 1905, p. 435. 


Removal nmv bo * r...,.iin..l for n.-w ^'mutlis .., „... . ,1.. 


case it is hut run'lv liHtt'U lor. iu»i — ••■ 

iivi' tin- iiniM)itanro ..f -urnHjmlinR \MrU. from the s»an' 

"••"'S:;;::;,^ 'oMh; entue clav.cle .or ...w growth. The foH«wi„, 

of sarcomata of \mw van.'s Im p . a. ,.l.s..^^lM xsitlui. ^.r^ nmo. 

m top.ther with abncMioe of sw.llin.' -t .1. ha-M will ,0 

l„„.c uitl. anv a.l.liti..nal nn.- that i> .-.lUiml. U) I le<>t) ..IN < f r 
w 'ls f/.n-..,.s nms, hoat l,a,,.l. k'.) i h- a.-ronual end shoiAl • et 

L na er oni^ -v.n. to their .lepth an.l th- wav Wiu . 

?1, t M. ,na V he tie.1 a..wu t.v the growth. (7) VN .th ,H-n..., -an 
U f anv .Inration. outlvin^ proce««^ may l>e prenen • 1. t - 

ho touanls th.. inn.T ..,.,1 -f the gnmth .t , ^ 

«ea est caution t.. a „i.l ..p-.n.' up .• t,s«ue whu-h w con- 

Km« with that of the n.e.hastina. (f D.v.s.oi. of th.- eh. e 
JmetimeH taken t.. fanlitat- it> ■ .....val s ....... av.,. 

if DOMible. as the wouml mav thus h..,-.uu.' '.-•t.-.l w th ^.^^tl, ( I As 
nKmoval ..f »«ne8 infUtratod with gr..« h th.- . lavule nu;> l.-a. .u re 
Ch", .. Uatiou ; the outer end should th. n he s- .-.l w, t h h.a. ..-■ep. 

a„.l ,riss.'. te,l out m as to give more room for deahng with th. m r„»i 

'^'SStion. A ..ontal iucision i ..a.l. ,h.„, the w ..h- 
of the clavicle, with a vertu-al i.^cision if n.. -sa . v over th- .m.s- pr. 
nart of the growth. The skin and fa* .a- a ■ n;rieote.l s- as to 
S?)^;h.-'M-fi.W aspect of thet..,..^ Th- cL.. ...lar h, 
sterno-nv.stoi.l the clavicular attachtn. is of t»r -.t lah^ 
T"\ . . , 1, , l„s are th.Mi Uvided h ..lui the hnut« 

W aelt.>,a.auathetrap. ..usareth.-., hvd^ h -^^^^^''^ 

gro^^th. The acrom.o-clavuuh.r j-unt then -n«l '^.^'^T^,, 

Stremity of the bone drawn stnmgly f. ar.l. u,- ^>JP- 

of a blint hook. The subclavms mu ■ an.i a ncn . 

and rhomboid ligaments are then sevrrr ■ h « k .-^ tm 

.rr,.at.>st care h,'m<i taken t.o avoid injury w tnr ::: ;u '"^J "TrV 

po nts are illustrated in the following case bv Ir B.^ .«»n Jessett* 

Sf removal of the entire clavi. ' for a large pen.- leal .ma. 

» Lanf. ISS'J, vol. i, p* 1077. 


F".X( ISION OK TkiK rl.AVIl I K 


Thr |> It II I ' ttii- .1 I ' ' Iti . ' 

llli'l 1X1(1 liil .\rf 111. Ill ■ l«ii liii. 
■ i.:.f |uiil) - » I, li |i il II ur •hi., r. 1 
'11.. ; .. I I Ii.i! • i;iiiw I \ I . , Iril iiKi 
int. til. til rk. tt Ii.kI j I 
run 'I any |ii. -iirc nii ' 
im i.- It »iiH iii.iiti-, thf I' ' 
-I'ltivH'iiiur joUil nil- ' 
fnwt Mm- Ikhic iit fur i. 
'liviil. 1 Til. I" ■■<■ WiiH 1 
' hinl- \ II 11,11 1- -«w mil infh lii'i i.. •■\m, w- 
. >im . nil the SiMlH' . 

!• 11 ■ lllis » , ..; .l'|'la|>|l<'li 

I !.!-' iii.iili' It (In 

1 I .< it i -in> aftrr 


|i<i!.<il ml thi 
M iIk i ,tl th. 

I" .|H' 1.11 . |1«. Till 

till' ^iilii'la> iuH \ 

lil llll V « l> 1114't w 
>. til'.' L'lll«lll ' 

nil 111 i|i\ nil n 
ilili ill liiL'iiii; !■ 

■ \\,i< t.ili. n 111 I. i 
iliT pati 1)1 till' .■ 

II L'I'iWlll 
II! l^llll' I. I 

I'lmnvi 'I aft" 
st-n till!- ' 
liitir ■■ til. I 

IWta, -in'iikini.' iit A iiuK>titit;of tlH'Mt'tliciilSiK'ii 

p ' tim itt jrri"*!!!" It nl iMt'ii rrtimvi''! 

.u I h tt . I if 111. iiv 1 ii.iii a ^ 1 ar - iliii ilioli. 
! till' , 1..^ !.■. ■| li.- fiill..«iiii: 
iiirii. I ii|HTat Hill. 'I'll.' .itfi- ill I 111' |i.i' I. I.I. 
flirllliT oil 111 111!' rll' -l W ill ll III il <ll'l 
. (imit <if 111'- i lmrlr aii.l li.iil .iily lati'ly 
III' »|, .11 HiW lutt iiiH''i<"»*<'''- •■^ — ^-mIiu|iihI 

IJ the . III .■ Il' HIhI ||h> Ktlli' ■ 

iM iM'iiiv iltH-tiil. till- niiiw't. ■ 
iliT filinn of III. 
iitu'liim i>f ill'' 1. 
II I fiautiii'ii' «.i~ 
iiiri'fiilly ili tarlu 
ill ii|H'iiiiii; I III' Ml 
V fill' lirr I'Mi'iiMi HI 1 
. .-Ill 1 I.I \ ii-iil 1- 11;; 1 m 

.Hill till illi.l ..' ' ' 

.1 till- >1. iii.'l I . 1 
iImm .-ii'i/.i'il wi ll ■ 

Ki- lllllnlK I 

ivii li' ttai 

ilivi-ioli of thf iiiUHriilur iinil liKaiiii'iit'niM nttai-lini 
■ if iiliHxi, Tin- futtii'llt umili' a (JimmI n'i'Ov«-ry 
■■im-ntM wi-rt< M{iiaUy gwxl with ttuw.- of l - • 
" .Mr. .li'^M'ii 

H«> over ih< 

v\. If iIcIiM'IhiI 

'•-fiio miiKioMl 
r iiiiit ini)liili' 
lii-n |»«II<hI fill ■ 

' will. M'!"*!!!'.! 

nil l l . ii-ii' If 
llii> 1. r ' ' 

' .\lll ll u 

' ■'.i' ' .1 
1 .,f !■ 

; .n I.. . I .1 
. ill. •' fltoiith 
.ii»ttf "Kh'."' It. 

It i»«'V«Tll Hmnli 


nillH'las ills coulil lint Im' 
riii.'< Ufi atly ilirli-.isi'd till' (lilliciil 
'HHiL'li liiiiily .iillii lrlit. wa» liiiall\ 
"1 111.' kllifr altriri.ltrly. Till' I 
i. Iiiil iiiaili' a jtiiikI rrciiM i v. 

In i .1 M..II - 
th<- 'li^ i • .1 Ilia.'-- 
clttx IV 1 ulii.-li 
the 1 .mill. .111. Ill 

tW('llt\ 111....!'.- of 

(•an'oiii . -til' M/.i' Ml ailiill li-l-. TIh' iirrn. 
|«ii..'iil -ili alliiml ll. J iliii' 111 III.' i!riiHtli). -Iiiitti il 
III. ai l iiial 1 Mil liail I.. .11 li ft, tin- ii'sl nf tin- -.itr 
ligailH 1 ills '..iml. All. I till' I. liter. no clinil.t. is tin 
wliPlH' I 111- -ti'i- iisi' of the liiiili has Ix't-ti sn ^ikmI 
li.ivi' Im'i M jx'rfi'i't. 

lir. ^ iighaii iH-rfornM-tl comiilfli- •■x«'isi. .r 
■nth" i.iUT tif niitii wiiH in gocnl iKitlth, aii 
man "> u uti-amlxiaf . Hen- It wan thmi({li' 
-iiiiil I tra|» viiis 111 r(ii'rrs|Mm(liir.' |ioiiits . 
' : .1 Till' i'\ I'lli Ml fiiiii t iiiiial U s lit .>. i -'.HI .Mr. Synionils n iiHivi'il ll. . 
Til III. Ill' 1 1 limir wax lii't'r iiiasUi il liy ll 

I, it. i .1 Wi ll ll. In ■■ll. Till' iipi iatinii w.i~ I'l l 
fil l' lili i iliiitr ll all I .lint-, till' I'Mi'liI 111 ■■lii. 
I'oiisi'ijiicut ilillicully of gittii>K at tin .n' 
ligiinu-ntM. The pittient made a rapi<l nn . 


,. I 
I if I 

.] ll. 


.nil i II 

ii.-i- III (In 

I in 

iti'il uil h 
tin- siili- 
.11- ll>r of 
-..11 111 
I- (till' 
nu ll of 
.1 liy II 

i.s ..ttiit to 

.\ i|i.)l Niircoma. Twi'Ivk 
tfii : lUf! oil Ills Work a* a 
siitiii. Ill tin ili'la. lull sli-rito- 

•• . i.inilis ami ili lloiil li.iil ."ll- 

ii'li' fin il inixril 1 .'11 

iiiu III. ami III. I 
'll lilt ' nil I lii'iiii. 
" I.' I.' tt.i- til ■ 
'.i\u'iilar anil 

iiiiinl. oil's iif the 
!i..iiT In III. \. ry 
.l.'wii. iinl llir 
nisiii I l.iv 

I rfiiiuiiH'ti w«'ll il yvur liili-r. 


\ I M . I?i atson. 

|)a|iri slinws till- usual 
lir lixit \ w liicli Ilia '. I.0 
11 ilii. Till' Sdoiiil rib. 

A casi' III aiiL'i'io sai'i'diiia of tlir ..' i- 

of (ila.sjiiiw . ' 'I III' iliawiiiL' a( i'iiiii|iaii\ . fj llii 
pliibuliir .swclliiii.'. ami j.n\rs as ninnl an . a ul 
ni"t with a.s it i.s |i(issil)lt' liir an iliiLsliatiini 

wlitnv I'lodi'd by tlif omwth .ifijuiml prngiiij:. hikI souk- fiilarm'tl 
glands, tlie nature of whith i.s not given, wen' n'n»ovf»f i In' |Mistorior 
trianfili'. and si.x months hitt r a furthtT removal of glanffw was jH-rfornu'd 

W'liicli thi' iiiicios. Dpi- ii'ft 11 dociit.-'l whi'ili.-- tlu'v ^v. ^" saicomatmis 
or inllainiuator\ . Vet tla' ; ient was aliM and \\>'ll tun years after 
the first operati«Hi. 

' III a ca«ii- of .Mr. Cwldy'-. ' il. ni ' 
inniT two-thirtis "f the r -'lit . i ., jr wi i. i. iin. 

uiiil iiiiniiiiiiiaii' M --. i- i 11. .;.-..! ll 

iliiwn lit'liiiul tin- .1111.. 'I ii.' [Litii-nt ir. ..\ 

^ Amrr.-luiin,. M'-l. in. t».S. ji. Hmi. 

Mi d. AVu«, .Iaiiuai \ ». 

* Brit. Med. J our II.. itttli. vnl. I. p. \iH. 


H.r.. X.ivi iiilier 111, Ih'.li). in wliii li the 
K'll for a jieri.'stfal siircinini. tln' |ileiira 

att.iy a t<.*.,.M- i.f >:rowth whit h jia. . 
.•r«l with pn<f^-t tnovwnciit of the arm. 



A po.,a instanc e of partial removal of the clavicle ia recorded by S.r 
J. Blan.l Sutton : ' 

- H..n. ,h.. a....„ua. half wan w.'ti; n:";:;;; ^ai-i:' 

Tl... . hirf <limcultie« met with won-, ^^^t- •^f^''''^'^^^"^^^^^ lipnn. uts. th. sc 

Htructu«-H requiring careful '''7^ I ' n ,.'-'<'•• aiul «,.s rrlU cH-d without 

„..rve ran in a Hhallow groov.- ''I'^X ;"^^^ ',!^^:^: of . um-nee. A Hbrou. 
&u„Sft-'::::^^n"'oMi" '^^^^ -nC the patient eouU. 

.,f a tl,yroi<l t...n».>r ..f tlu- . avuU- ''^ .^^^^^^^^^^^^ the thvroi.l i" S..,,t..n.l.. r 


painful s«olli„g of th.- ri^ht > " ..^'Tla I '>y 

"carriimtua, though .ollpid material was absent. 

,v««.oTft«*T rnwnrnom OF THE CLAVICLE, ACROMION, OE 

\ v*.«tn>M Hi the clavicle. Opt'iativc interfeivnce may. very 
rJy f?r in soiTof the foilowin, .ases : ,1) In ---nt n..-^ 

wi^l verv marked displacement difficult to reduce or keep ... ..... 

si, rut. re of the acromial end. outside the J'^; . 

• l„ ,o...nou..d and (•on.n.i...ited cases, after the woun 

;en'; p.o...ote asepsis, win... ..f the f-^mentB wju 

t unite justitiahle. espeeialtv .1 thev ;. , J^^^^^^^^^^ 

nervt s.'perve-.e.l later. moSt successfully treated, has been recorded 

bv Mr. Barkei/" 

" A „oy. aK... ... was ..o....... ^J^/^'r^.'^.^-. ll^^T^ ^ 

painful Hpanm. rendering the r «i,„ its r.uls .... the elavide 

^ Mr. &r niade an in...s.o,. ;<,"^, ,^ fo . 1 was t,.n.e.l ui.ward. 

and i«H eonvxity «> 1 h. "V"^ . f,, then dividwl 

I r/i'i. .'•'"f- Trnii".. vol. xxiv. ji. 12. 

a J(i»r«. ." « !/.. vol. i. , ., , ,,„. , u. i, li. ilo<-* not l ausv the iifttii .it 

Utrophied, the miiKclM will foun.l liyin rtrolAW. 
* rlin. Sor. Tmnt.. vol. xlx, p. 104. 


lali r till' |Hi\vi'i' iif wiitiiii; was foiinil to lie riiin'li liii|>iuvi'il. anil llic ,11111 rvi iit iially 
III rarni' pcffi rl ill all its fiinrtiiiiis. 

Mr. liiltoii l'(illiir<l ' I'i'ciirils a l asc iif iiiuiiiiti ii frai l lire of alioiit foiir niuiillis' 
liumlion, in an infant agt-U fixhtccn montliM. in wliit'li he rt-stH-ttil anil wirnl the 
fragmcntM with an excellent n>ult. Soiinil union followed, anil tin* arm. |ii'e\ lously 
hanlly ummI at all. was movcil as well as the other. 

Ill tliosi" casi-.s wlicic iiiuch ilcfi)niiity has followed union of a frat'turctl 
clavicle, especially where a |>(iiiiteil process of hone projects under the 
skin, it will be cpiite jiistiliahle. with strict aseptic precautions, to explore 
and to remove the jirojectin^; bone with an osteotome or saw. 

Fi. Dislocations. It i.s well known that ixca.sionally di.slncation.s of 
the clavicle, especially of the sternal end. are most dilliciilt to 
inaiiit 'in in place after rediictiiiii. in these cases, especially where the 
sternal . iid has been displaced backwards or upwards, in which situation 
it is liable til |)iess u|)iiii the trachea, cesophagus. or lariie veins, operation 
is indicated. The di.splaced bone is exposed by a suitable incision, anil 
then, after resection of a portion of the extremity, the dislocation can 
be reduced and the bone wired in position. 

In IS!t!> .Mr. Jarol son reinoveil (he sternal eiiil of the elavieic for an olil disloca- 
tion upwanls ami liai kw arils in a patient at (iiiy s Hospital. Only the eartilaKC 
re(|iiire<l to he reiiiovi il from the sternal facet. The wire was reinoveil in thri'i- 
weeks. When the patient left the hospital, live Weeks after the o|N'ratioil, the 
deformity was l utin ly ri iiiiueil ami the iiarts were soundly cunsolidateil. Four 
weeks later he hail n siimi il his work. Hf could raiw! hii* arm to a right -angk'. 
and the iiioveliii iits hi re ini n asiiij;. 

Ki seil ion of the ,ii riimiiin rlaviiiilar juinl was |H'rfiirmi'il as liin<; a>.'ii as ISIll 
liy an .\iiieiicaii surgeon, Cooimt of .San Fraiii isen.- He lesei ted the joint in three 
caws of acrDiiiio-clavicular disWation. In each case the k'sion was of several yearx' 
Htanding. and the usefulneHs of thi< limit much inipain-d. In all three the result 
wuM excellent. Mr. Ja^obson ha-t o|ierut«Hl by resection and wiring in thnv rawii of 
aeromio-olaviciilar flisloeation. two of tlu-Kc lieing primary and ime a tii-<-ondary 
o|M>ratii.n. In two the result wiih |M-rf(vt. In the thirtl. one of the |>ritmir>' ciiMeM. 
infection folliiweil. .iml the wire had to Im' removed. The (k-forinity wan. however, 
n'moved. and the union was secure. 

('. Disease of the ioints. It is well known how ub.stinately tuber- 
culous disease soinelinies attacks the steiiiii-clavicular joint. The 
simplicity and the superficial position of this joint render erasion, 
followed, if need be, by riMntival with a chisel ()r twteotonie of one or 
both bone ends, a nuwt successful dpeialion. 

' llril. Mill.. I mini.. ISST. viil. i. p. liTli. 
• .imrr.Jimrn. of Mid. Sei., A|>ril IWII. 



n. -v vi/ tli..s.. f..r lain." fil-r-Mvllulur firowtlw and tha vascular 
will require mention in a work hke thw. 


Tlu'so rare growths, occamonally requin- nMn..v;.l. .... "f ;?;;;;^ 

I I ■ .lof. r.iiitv ' The chief points of i...i.<..ti...c.- ... s.i.l. u| 
^' T , Thrn.av be terrific.^ copums an<l wo.-,.....' 

Zu. • . ' . owi^^ the hu,e si... of t'.. growth and the vase., a nn 
• V It iv l>.wt ..i.'t l.v a.i ;iit;.-mous precaution «t Mr. 

Mv ,. tl... eves Nowadavs inaia-n.l.l..T tul....jr which a.. 
later oi\. i;.. a,. nfti>r extensive operations, and 

in gj.„i «••■'<'"'"-.;■''";•-;;!;'■''.;:;;;';;■,■:;!'!;; r.., hero twi... a> i^rKc as u,.. 


Mommi vf musttmm (OHoid ameurysh) 

Tlic tifiitiiK'nt of thfse sonietimt^s most (UilicuU casfs is given wider 
tlif head of • l.igatuiv of thf Extcriwl Carotid." 


I'lider this hoadin}: rcftTcnoo wiH bo n\m\« to (I) Kxowtjwfs ; {'i) tluww* 
iiiali^riiaiit ^Towtlis. u.siiiilly sarcomata, which. >pnii};infr from the waip 
(often the ixMiciaiiiiim). tlic »lii>li«'.' tiif iiicniiii."'>. and. iiiort' rarfly. 
the hraiii. an- caiiiihlc of ixTforatiiii.' l !ie .skull Ikum witliiii (.iitw.inls 
or ill till! ri'vcisi' diivition. (•"•) E|)ith<"lioniiit,i TIhvsi' ;rro\>tlis .hc 
the oiie.s ill which tlic advisability of operation is iiii>st lii<cl\ to jui.-*-. 

(1) ExoKtosea. It is only the ivory variety that needs reference 
hero. Those o.xceodingly hanl slowly growing tunio»r« iwuaWr jsrow 
from the flat liones of tlie skull, espofially in the walls <»f iwHital 
.siniLS or in the external auditory ineatu.s. The best incision to •-s^fKiw 
it, in th(; former situation, is one tiansver.sely outwards fi<iiii tlie lo.-' 
of the nose. tlirou;,di the eyebrow, anil anotlier upwards alonu' tin- middle 
line of the forehead. The anterior wall of the frontal sinus must be 
freely reiuovetl with trephine or chisel, for it is essentiai to get at the 
root or base of the exostosis and to divide this, and not merely to break 
off pii'ces of the exostosis. For division of the extremely dens*' bone 
a burr worked by electricity is preferable to chisels and .saws. Where 
the latter are relied upon .several must be at hand. When the pi'dicle 
is detached there is often much ditliculty in prisiiij; out the exo.stosis. 
The surgeon must be prepared for opening the posterior wall of the 
sinus and exposing the meninges, and perforating the roof of the orbit, 
and the delicate tissue of the ethmoid. In 8»)me cases it will be well 
to obtain leave to remove the eyeball. Careful drainage must be ptti- 
vided for the (list few days in case of infection from the nose, and for 
the .same reason the wound should not be too closely sutured at first. 

(2) Sdrcoiiiiilti. l'erio.steal. endosteal, and (uifiinatiiii; in the 
dura mater. The following remarks by von IJi'igmann,- by von Brims, 
and von Mikulicz may be useful. .Sarcomata of the skull may Ik* 
pori»)steal or central. The temporal hniw is niost fr«'<|uently attacked, 
after this the frontal, parietal, and occipital. Riven at an early stage 
the surgeon has to face the ipie.Htion whether he is dealing with a sarcoma 
of the skull or one perforating from within. In tin' majority, whether 
periosteal, central, nr from the dura mater, spindle-cells predominate 
Those ari.sing in the dura mater are characterized by calcitication. 
In large priosteal sarcomata the abundant l)l<M)d-supply may lead to 
distinct pulsation. At a very early stage this form shows a tendency 
to bv .secondary nodules, seated at first near the base of the 
original growths. This tendency to local dissemination, which can only 
be determined bv tlie microscope. ex])lains the freipiency of reeuirences. 
Metastases in the vist cra. especially the lungs and in the bones, are very 
common. The lymphatic glands, as a rule, are not involved. 

' \\ hill- till- vaiilt i.s alfocted more often than the JxMo, gamimitta of the ukuli may Iw 
|ircK(>nt in lH)th Hitiiatiims, Himult«iu<oUNly. 

* SgM. nf Praet. Surg., by von BergmaBn, von Brutiit, Mid vun MikulU-x (.4Nit'f. TrttHi., 
by Dr«. Bull mwI MMtin. vol. i, p. 124). 


()„]v i„ tl arlv stau.s. an.l uiuU-r (■..mlitioim rarely present. 18 it 

^ to « lu-tlu. a sarc-nja of tlj. skull ,s «;-»™ .F^I^S 
Arises fr..,n the dura mater. If tin- smta.o !»• haul an 1 I " • "^l;" 
it can onlv be a central sarcn.a „r , Humbly a local P;;;';;; - ^^^^ 
oetosis. Tn central sarcoma the surface soon becomes alteu .l b> sot i 
whic h l.ul.H. outwards; ofUn, the summit of the swelhnu .s s, f t 
"^ile the ,.c,i,.ir-rv renains hard. In this way the «PF"«';- ;;^> 
similar t.. hat of a ,..Mforatin}r sarco na ot the , ura mater The latter 
h^ ver. never liftJu, the bonv wall of the sku 1. but .^stroys ,t by 
inHltiation ; the Rrowth is therefore surrou.i.le.l by a bon> im-. Ihe 
X 1 however^ on a level with that ..f the jzen.-ral surface of the 
sS and does not. as in the case of tlH^eentral sarc.Mua p.en.l m 
th.' bas,- of the frrowth towards its suuauit. In the ol the u-i.tral 
CM, tl e out;- and inner tables feel as if thev had been forced apart 
I ile in that of th. ,,eriosteal sarcon.a the tables show a jagged edge 
if even- periosteal salcon.a were con,p..sed .>nly of so ft tissues .t would 
be easv to .bstinnuish it fron. a central sarcoma, as Ion- ^ a 
possessed a bony shell at its base, if not at ,ts sumnnt. ^^-^r^^. ^^ Z 
larv^ti of periosteal origin, a fn-Muent -rowth. has a I. .> • j 
?;,th at tin- peripherv and summit. The latter possess no bony sheH 
u nmneroui sp cules of bone extend into the .nowth from the s.te o 
its attachn.ent. On palpation these growths give the of 
1. nv psMle. and 'tin's leads to n.istaking an "^teo-sarcoma for a 
central .sarcon.a. The n.ost •••■rtain of the ..n^nn <.f a ne« 
«owth in the diphH. is th. presence ..f the bony wall nsm- «bove the 
fevel of "he surface of the .skull and extending towards the .unmn 
the gr<.wth. Sarcoma of the dura mater is zed m. .^xce .t.o J 
cases c.nlv bv the above-mentioned peculiarities <.f the gap in tl e skul 
Its situation within the plane of the surface of the bone, and its sharp 
utline It niav be diagnosed earlier by ..ther svmptoms. If 
reviouslv existing symptoms, especially those of -tracra.ual p« 
disappear as soon or soon after, a tun.our appears at the surface o 
ThTB. the surgeon is safe in assuming that the 
in the dura. Such a tumour begins to develop witlnn the cianul cax it> 
and brin.'s alx.ut .svmptoms due to encroachment on the intraciania 
; itv As .soon as the tumour make, its exit from the intenor of 

the skull the diminution of space and ♦'''V^*''""*'"" " ^''S 
resulting therefrom cease. In th.- .s.-.ond place, per ..ratn.g lura 
sTrcoma usually pulsates as a result of the pulsation of the bran, bemg 
toTs^tt^l tJI Tn the third place, such a tun.our '-^v '.e or.ed 
bv pressure into the cranial cavity, causing temporary headache, sloping 
of he pulse, and lo... of consciousness. If these three sympto.ns be 
pre -nt'the surgeon can with certainty .liagnose .^arcoma «f^ dural 
Erigin which ha.; perforated the skull and contn.ue.l to proliferate out- 
side. C.H.verselv.' he cannot, however, exclude the dural ""gin a 
growth in which the characteristic symptoms an- abs.-nt A n mir 
Ly be so closely adherent to the edge of the- defect ... t - ^^ '^^^^ 
no pulsatio.. of the brain can be transmitted to it. or that pressure 
Cannot force the growth into the cranial cavity. The I--'< ;" 7;^^^^^ 
svmpto.ns a tun.our on the .surface of the .Kuil has no 
tearing on the c'liftVrential diagnosis .....h-r duscussion. or penosteal 
as well as,.c,us. growths n.ay prol.ferate .nwa.d v as veil as 
outwardly. The diagnostic importance of cerebral symptoms depends 


upon tlif fiut that thi'v occur iK'fore the tumour beromes noticenblp, 
ami disappear after it has made its appearance on tlu> surface. As 

soon as the tumour reaches the surfac f tin" skull it sjireads out to 

an extraiu-diimrv degret', the defect in the skull completelv covered, 
and there is no longer anything to distinguish it from periosteal ami 
myelogenous sarcomata, which similarly piolifenite and attain an 
enormous size." 

Tmilmrnt. It remains to be se<'n what op»^ative attacks, aided by 
nxMlern sur<rerv. may avail in these cases. Imt for the present, unless an 
opportunity arise for attackiiitr such fzrowtlis i|uite early c.;/. while 
they are only of small si/.i' it will be wiser not to mferfere.' .\nd this 
warning is especially true of those in w hich san •unata of a specially 
malignant kind appear, often after an injury, on the c rania on children. - 
where the swellings of the scalp are nndtiple. or where they are travelling 
out of the skull by any of the apertures, e.if. the orbit. Large size, any 
evidence of ti.\itv. duration of any len^'th will cause my opt>ration to 
be .set aside, owing to the dangers of the operati(Ui. the p>ssibilitv of its 
being incomplete, especially where thi' brain is involved, and tiie risk 
of its being impossible to chise the gap. In addition to the (piesti(m 
of metastases in such cases, the fnMpient piesence of niktBte kical 
secondary lunlules (nee p. 245) nnist be remendieretl. 

The necessary difficulty and tediou.sness in isolating the afftTted 
bone, if of anv si/.e. by sutlicient trephine-crowns. and joining these 
with a (iigli s .savv (.vc p. :{|4). or the force|)s of De Vilbiss (.see p. '.\\'2). 
or a chisel.-' It nnist be remend>ered that the overlying soft parts wen- 
e.xtrenielv vascular and perhaps (from the enlargi'd <.'lan<l) already 
involvetl in the growth. The po.sition of growths will not always 
admit of the use of an iiulia-rubber band round the head. In i.solating 
and going wide of the affected bone, it was imcertain whether one or 
more sutures wouM not he cros.sed. and .sinuses, such as the supericu- 
longitudinal, met with and need securiiii: (this, whether by miderrumiing 
or otherwise, not being always an easy matter), thus leading to profuse 
ha'morrhage. In addition to this source of luemorrhage there is that 
certain to be met with in dealing with the soft parts and with the 
diploe an)und the affected bone, uidess this be extensively sileroseil, 
when aiu)ther difficulty presents it.self. 

Then, supposing tiie hone sufficiently removed, wide of the growth, 
ill many i)ieces. either because of its involvement in the disease, or to 
allow of further investigation in the case of a growth of doubtfid origin, 
if this be fcmiul to aiise from the dura mater, this ni( inbrane nuist 
certainly be dealt with, and the sanu> wttuld very likely be the case if. 
originating in the diplm-. the growth had crept inwariU. In further 
isolating the disease, if it had merely pressed upon the brain and not 
involved it most delicate work would be recpiired ; enlarged branches 

• An intcrc'ftiii); is piililishi'il liy Sir. H. Miirri" il'filli. .SV. Ti'iic-.. vol. XN\i, 
p. 250). The <li«'ii»c> licri' frtaiiil.v took .six vears in ruiiiiiii« its coiirsi ; otlu r (li |)iisit.s 
wen' pn'si nt. Tlic patient clinl iiwny fiorii l,<"iiiili>ii. 'I'hr !.'rciwtli is stateil to liavi- l« i;iin 
ill thr iliploi and to liavr 1 oMipri sscll. not invoK ! il. t lie liiain. Dt. Drumniond of Nrw- 
cttstlc. pnlilislu'd thn<' intni'stinn rnst-s [Ilril. Miil. Jmini.. iHKi. vol. ii, p. 7(12). In 
none of them was o|XTiitiim |Mw«iblf. Other inntintw of nan'onmta of t hv cranial liom-s or 
the dura mater an- H^iired l)v T ilmnnrw {Tfrt-lmot ofSiinj.. vol. ii). 

- A i.Moil in,-tain i' of snrh Iniumittii- sarc.nMtn is re* orded, witl. i!!ii-! hy Mr. 
Hcwi tson. of Voik (/.""'■''. vol. i, l>. 1441). 

' The best means of removing bone from the .skull on a large siale are givon at 
pp. 311-313. 

'its ()IM:H ATIOXS ON TlIK llKAl) AND NK( K 

(.f the miaaie meningcul ami. very likely, .lilatwl siiiusos woul.l i.M|uii.; t.. 
be dealt with. If the diseaHe ha«l invoK .-d. instead of merely .li.-^pliu iiil'. 
tlu- l.rain. n.-w aiul s|)ecial risks would have to be encountered when 
the imtieiit"s ...i.diti.M). after an already prolonged operation, was least 
titte.l to Imm!- them. Thus the operator may find that he is dealing 
with a non-ei.capsnled >;rowth of the hrain itself, and all that he can 
do is to trv and shell it out with the fiiifier or sharp .spoon Lastly, 
the arrest i)f all lueinorrhage and the possibility of closing the wound 
and gap in the skull, usually by a second operation, if the patient survive, 
have to be renieinhered. 

Such are among the chief difficulties and dangers which are very 
likelv. if not certain, to Ix- met with. _ . ■ . j i 

Moreover, in th.'se and in other prolonged oi)eration8 which (leal 
with th.' brain and its membranes, the fact nmst never be lost sight 
of that, with all the nece,s.sarv interference with vital organs, and wliat 
with the anR-sthetic. the margin left t(. the patient b.tween lit.' an. 
death iiiav be a very narrow one. Even if the growth is siimll and 
circumscribed, and there is good reason to In-lieve that it i.s single, it 
will proi>al)K Im' wise, to divide the f.peration into two stages if the 
dura mater 1m- involved. 

The results given bv von ISeigiiiaiin.' especially when due weight 
is given to his'uiiusiial e.xixMience and opeiativ skill, do not .--ein 
encouraging. The last sentence referring to •■ ca.«es apparently per- 
manently cured" is tw* vague to be of any real value. • Ihe antlioi 
has done e.xtensive resections in four of cranial sarcoma ; in one 
of th.' i.atient (lied. The tiinaair had prolif.-rated a considerable 

depth into tl cipital lobe, and the profuse bleeding which resulted 

caused coltalise. The three other patients rec(,vered. I wo (lied at 
the end of one and a half and two vears. respectively, as a result of 
recurrence of the growth. Regarding the fate of the third, he was not 
able to obtain anv information. (Jruiiberg investigated the histories 
of all »)perations published during the last two lU'cades. fwenty-two 
operations were perf(uined on seventeen patients. In three cases two 
or more attempts at interference were made necessary by recurrence of 
the growths. The oix-ration was completed in seventeen I liree 
of the patients died as a result of the (.perafion. (leath being <ansed 
by entrance of air into sinuses, thrombosis of sinuses, and cerelnal 
abscess. In seven cases recurrence took place soon alter the operation. 
In two no information was obtainable. Of seventeen cases five were 
appareiith permanenth- cured, which is a gotwl result, considering the 
hital termiiiatioii otherwise." • ■ r i 

(:<) Another .similar, but distinct, class of these growths is lornied 
bv those epithpliomata of the seal]) which have extended through the 
cranium to the dura mater or even the brain. 'Iillmanns - gives good 
illu.strations of two such epithelicmiata involving the Irontal region: 
one. in a girl of 14. which perforated the skull, was su( cesstuliv reniovetl 
bv Hraiin : the other, in a man of •"><-. was operated on by Tillmanns. 
Here recurrence rapidlv took place. A very instructive case of carcinoma 
of the frontal region, involving the skull, was successfully ojierated on 
bv Mr. Battle and is fu!!v described in the r.'/,,. .s',,,- Tnn,.... vo - 

xxxii, p. 127. Mr. Shattoek pronounced the u'lowth to be a s|)lieroi(ial- 
celletl carcinoma, probably originating in the glandular structures of 
1 y,„r...H^,r«ri7.,i..l48. « Sarj., vol. U. 


the skill. Mr. Battle's remarks on the mode chosen for rem 'the 
cranial bone are very noteworthy : 

"Of tho |irinci|»l mpthodH of niiiovinc large iM>rlioiis of ili.' >kiill. tin- "iw 
whirh wan brought to ray notice l>y .Mi sxrK. Down tliiit of a < in iilar Hiiw workiil 
l>y a motor apiM-arrd llii' most lilirly to fiiliil the olijcct in a satisfactory niariin-r. 
T'h( !\' was. however, iniieli (litti< iiltv in Kiiitlintr the saw aloiifr the line whieli 1 hail 
sele( ted. and it travelled slowlv thronjih the dense hon.'. whilst the eahle attached 
to it was euinliroiis and ditheiilt to hold. Were I alJain eall. il himmi to jM ifonn a 
similar o|K ritioii. or one re<iiiirinf; the e\eision of much Ume, I shonhl use the 
method, since sntryested. of the wire saw. worked acloM from «ie trepiiie oiKning 
to another, and applied from within outwards." 



onuasn nmriBDicE immediate or later' in 


IniiMttoBt. The cliiff are : 

(1) Compound depressed fractures. Whether syniptoius of com- 
pression are^jresent or no these fracturcB should, iis a rule, be explored 
bv reflecti>,u a.lo.,uate flaps, then elevating any depressed fragments 
aiul re.novinf: anv which arc .,uite loose. At the same time the surface 
of the dura inafr. where c.xpo.scd. should be carefully .scrutmiaHi and, 
together with the rest of the wound, tllorou^lliy cleansed. 

Operative interference is indicated in these cases tor two roas<>ns : 
(n) Even if no svmptoms of compression are present at first, st'condary 
inflammation is verv likelv to follow in a few days, it not havmg Ikhm. 
possible bv .-xpectant treatment completely to cleaiise the wound. 
If n..w. some minute frafiment of the brittle inner table has mrickwl 
the dura mater, fatal infective menimiitis is almost certam. Should, 
therefore, the surgeon, in those cases, vuit f<n' evidence of compression 
as a justification of operative interferenc.". he will too often wait till 
it is too late. Evidence of the presence of dirt, especiallv of dirt ground 
down to. or into, the bone, is a reason for exploring the v/ov even 
if no svmptoms of compression are present. (6) If the patiei ■cover 
from the immediate eflVcts of the fracture, injury to the innei table, 
insufficient to cause svmptoms at tiie time, and not detectable .s*ive by 
an operation, mav be present all the time an.l cause senous future 
trouble. In the words of Professor Nancrede : •• I ndoubte.Uy man% 
patients recover in whom the bone is not elevated, but in to., many 
epilepsv. insanitv. chronic cerebral irritation, Ac, render life a burden, 
ami operations arc then rcpiired. which often prove useless." Operations 
for traumatic epilepsv show at times that in the effort to unite the 
irregular fragments, i»nd from constant irritation due to the cerebral 

I Hv Ih. M. t. it is int. tul. a t.. make a distinction between those oasos i.i «hi.'h 
.„H.ra ivc nt. rfere.,ce is nm.U- ..f « a few day* after a fracture a..; those in 


3 ..,1. i. ,,. S,.,. s,„.ak^,.. latcr trephining 

for th rrli- of oM .l.-prosscl frartun s. says " Although rcst.lts of those M-oondary o,*ra. 
lilms do not show a HaU..ri„. ..roonta,.. of s.-.^oss. • t^mk that tte r«j«>n ma>^^^^^^ 
for ii. tho late iH-iiodat which tho (.piTati.m is in-rformed. U w raw that tht iMtiu.t 
^bmits to the operation tiU year, have be... wasted in the vjUn endeavm.r ■' ^ - 
cure by medication. In the meantime, the co..stant .rr.tat.o.. »*f2l 'VndiZ ™in^ 
imprewion upon the brain and nervous nyste... which remain* after the offending pomt 
of uritation ha« been removed." 




pulsation driviiiR the dura mater against the bony fragments. Nature 

tliniws out (>stc()|ihyfic iimsst's. wliirh t'VPiitHj 'ly |t«Thap» iiftt-r years 
set up serious tmuhh'. " The surjiifiil f ri-atiiii'iit of tniumatii- epilepsy 
is now. when a larp- imnihtT of cast's operated upon have l)een earefully 
watched, found to l)e very di.saiipointinj; {mr p. 272). It is i>y u inoie 
frequent immediate e.xploration of all doulitful injuries to the head 
that we may hest h<»pe to bring about a diminishing frefjuency of trati- 
matic epilepsv. {<■) L«H*ality is, of itself, an indicati<m for interference. 
Thus aphasia may follow on a fracture over the region of the anterior 
inferior an>;le of the left parietal, and paresis on one. apparently trivial, 
over the moto. area. .Moreover it is injuries to the frontal anil parietal 
reifions which, if left une.\plored or insutlicicnl ly treated, are so liable 
to be followed by e|>ile|wy. 

A word of wammg is needed here. While the more localized is the 
depression of a fracture over the motor area, the more will the .snr^'eon 
be justified in interferin<; : he nuist not be certain that he will thereby 
prevent epilepsy in the future. Von Bergnmnn's words on this matter 
are weii;hty ones.' " .\s a matter of fact. e]>ileiK.y occurs as fre(|Ueiitly 
in connection with head injuries in which no fracture exists. Depression 
is no more a factor in the etiolojjy of this than any other scar 
of the brain or external soft parts that has become adherent to the 
skull. At present it is known that where an act of violence not exceeding 
the limits of elasticity of the skull flattens or bends in the latter without 
pioiliKini; fracture, the portion of brain underlyin<; the point of impact 
mav be contused. The cU-pressed fra^'ment of skull, beinfi ela.stic. 
spriiifis back into its former position, but the portion of brain injured 
at rhe moment of depression undergoes a st'lerotic de<;eneratioii from 
which mav originate an attack of Jacksonian epilepsv ; the same may 
take place as the result of damage to the cerebrai cortex following 
depreasetl fracture."' 

(2) Siitiph' (if pressed fractures. Where synjptoms of depression are 
present, operative interference is the only course o|)en. Hut where 
no such symptoms are present, the expectant treatment is by most 
surgeons held to be sufHcient. Wu may perhaps come best to a 
decision as to using operative interference in simple depressed frac- 
tures, without symptoms, by dividing them into the three following 
groups : 

(1) Where the depression extends over a considerable area, where 
it is slifjht in (lei;ree 0'-<l- not more than a sixth of an inch), especially 
if the patient lie yoiuif; and the bones yiel(lin<j. expectant treatment is 
no doubt the best. 

(2) But. on the other hand, where the depression is limited and defined, 
where the depressed fragment not only affects a small area, but is turned 
down an<xularlv or .'dgeways. operative interference should be re«>rted 
to at once, even tliouirh no sympt(m)8 are present, and whether there 
is a wound or no. to prevent the onset O' ^angers, immediate and remote, 
fully alluded to later on. 

There is a large class of cases intermediate between the above, 
where the fracture is a simple one. where symptoms are absent, and 
where the deprea.sinn is sufficient to cause anxiety, thousih not so sh;n jily 
defined as to call imperatively for operation. Here, when in doubt as 
to the severity of the the surgeon, if able to rely on his operative 
» oj Pratt. Surf., Atmr. Trant., by Dr. Bull ami Dr. Martin, vol i, p. 98. 


skill and on thewouml running an aseptic ••..uisi-. will .1« Ix'nt t<> ."xpioiv 
the fractiirp. This is psptnially the case in fnu tiirts of the frontnl aiul 
parietal r.-frions. owinjj to the frequency with whi<'h these are folU»wed, 

at II iatfi- (late. l»v opilt'psv. 

Finally, in aiiv fia< tur.' in wlii( li tlic <|iifstiiin <>f oprative inter- 
ference ariscH. thi' kintl of viulciKc miwt Im- iciii.MiilM'ml. Was this 
concentrated over a small aiva. and thus lik.-ly to l.rinir alKMit serious 
depression and comminution of the internul table, or wan it iiidire( t 
and diffuse, and thus likely to have produced a long tissun'-fructure 
with little depression, but perhaps tearing open meningeal vessels or 
.sinuses, openins; iij) the middle ear. nose, or pharynx, and spreading 
far into the l)ase ^ 

Inpwnre of silr. It is often said that a depres-sed fracture, even 
if distinctly marked, over the frontal sinuses, does not re-piire operativt- 
interference, and that any such steps should l.e avoided for fear <.t 
leaving a fistulous opening leading to passa;^.' of air and tnnihle.some 
einphvseniu. But it must be remembered that sinust's d«) not 
appear before the of fifteen or sixteen, and that, even in adult skulls, 
the extent of their development is most uneertain. the sinuses bemg 
sometimes represented l)v a small unilateral eel! instead of fair-sized 
bilatend cavities, other sites, which it is well to avoid in trei)hmin<:. 
if possible, are the jK».siti<- i of larj;e venous simwes.' that of the trunk 
and chief branches of the middle meningeal artery- and also the lines 
of the sutures, apart from any subjacent sinuses, as here the dura in.iter 
is firmly attached unless it chance to be loosened by a violent blow. 
Ajre. too. must have prop.-r wei};ht attached to it. it lieing well known 
that ill the first few v.-ais of life a very considerable depression niay take 
place after an injury, and \ ct be followed by absence of head symptoms 
ami bv s|H>ntaneons recoverv. 

(.*»") Ptmliind fnirlinis. Here, however slight be the injury to the 
outer table, that inflicted upfin the inner is certain to be much more 
serious. And the more the diploe is present, the more extensive will 
he the daina^'e whii h its fia^'inents. when driven down, will inflict upon 
the hrittle inner tal)le. It nnist he renienil)ored that punctured fractures, 
with all their serious ivsiilts. may he caused hv hlunt. thoiieh pointed. 
IxKlies as well as hv sharp ones. Instances of these are. blows with a 
pickaxe, fragments" of coal or stone. th<> trijrger of a clubbed pin. or 
falls on a Fender ornament. Immediate operative interference and 
here owinj,' to the limited injnrv to the outer table the trephine will be 
called for^-is imp' .itivelv deinanded in all punctured fractures, how- 
ever insifinificant i>e the' dainafje to the scalp and outer table. The 

• It i.s wiirth while U> in mind that if a larm- venouH sinus is oix-ncd. thr hicimir- 
rbaup can 1h-, u.-imllv. at ..nee arrt stcd hv vi i \ nHMlrrnle jmwiiir a|>pllr<I at the rijiht 
(•pot Th<- imwure" ^hoiihl at tirst 1m- niailr l.y the tinker, ami ki \<t up if mcdfal 
by »Btrip of ^terili- .1 ^'aii/i' Icf! n, for tw.. nr time .la^-. Sir II. CaimTcn {hiiiiril 
181W, vol. i. p. !t:!ll was aMc . .impl' t'' a t ri pliii.iiiL' wliii. very slisiht pri-ssiirp with 
lintcontroUca the blt .dins; from a w.amd in tin- sajK-rior loiij-itudinal sinus. Ho ixants 
out that the imaginary fear of fatal ha-nM)rrhanf may at timoH (tetcr from a nir. ssary 
oixration with the trephine and it ia well that it ohonld I>e dinMpate.1. Dr. llnpkms 
(Ann. ofSiirq.. vol. ii. p. tw) in a case of extensive . .iiipoiiiKl fracture of the skull, fouiiil 
th it jviiriU lint plu" lii'lilK ajiplieil to a wciuncl in tlje s\i|M i |or lon^ituiliiial sinus exposid 
hv elevation of fravmi'iils. r. uUW ane-ted the lia morrhajie. which iM rsevcrins! efforts ha< I 
faileil to i-oiitrcl l>y a li'.;atiiie. ''I'lie stiii lest precautions should 1m! taken when dealing 
with wounds of these sinuses owin^i to the risk i>l septic iihlebitiH and pyatinia. 

« The tTcatmont of ha'raorrhage from tho middW meningeal artery in given at 

p. m. 


tisngen of injury to the duw nwter and iM»ptH- infwtioii muirt alw» Ik» 
borne in niinu. The fulh>wing is mi iDi^tnictivf case : 

A <'Ukl agini tw.-nty monlhH was Irft aU>w I>.v iI-> iii<>lli<'r sittiiiu in a rhair. 
There were » nurah» r »( artU-lrH l. fl litti rni alxml i>m tli<- tliHir .immin wlil. li witM a 
nu-tiil IxHit-t™- |irolr(tur pnividril hiiIi llini- -li n |. iniinl-i fm' it. altiu liimiit lo 

the Molf of thf lMH»t. 'I'lii- . Iill.l f. II to III!' tl -ml 111;; lli" I.imiI |irnli i liir. wliii'li 

(iiinlv (Irivi'ii intn its fonlii i.l. On ,iilnil>-ion ■■> tin- lin>|iit;il llif plate wan 
Irvrli-il ,i»av and iiu . -I i^' at i'Hi Willi a |aul,. -Iinw.d ll il ill.- oiilir .if twii i.unrllin'K 
liail rr ii lii ii till- Imhii'. Tlir woiiml wan an uiiliniily i x|ili>ii il aiiil It was thru foiiiul 
that ihc lionr was |H i-forati il. Tlir nail likf iHMiitM Wtlw »o nholt that it waMlhoUghl 
that the dnru iimti r loiilil nut |K».«ililv U- ilama«iil. Th«> wimml w»m Ihwftw 
fk'nnnl and araimtl withtmt tn-|>liiiiiii'K. Tin- day- lat.T fin- «hiUI Imil wviw 
oinviilHionM, wIm'II tho wound wan aKuiii o|h'ii. il nii and ii diw of Ihmu- n'nwvi-d. 
Till- dura imter. wliH-h wan intomfd and iMTfuraltil. wan tnvW Uv'miU wh«-n wmw- 
i s< a|»-<l, Uiifortuiiati'ly tlii« wa* not lix idiMil. aiul tlH- <-hiH dw-d nrxt «lny with 
dilTiiM- HU|)|>unitivi< nH>ninKitiH. 

(4) In sniHt aiKt-M oj J'ractUrf almiit tlif inufr innih <>/ //«■ orbil. 'Ilu'si' 
ffmvi' injuries tiirhieh nuiv be caiiwd by •lin'ot vinlciici' from thruBt 
wmiiiiU at tlie inner anjili- of th»« orbit.'or nxrt «>f tlu" nose, e.g. with 
wissors. slate pencils, ferrules i)f wulkiiijj-sticks, &<•.. hHouW ulwavH 
be expiorcil at once. 

.\n iiuisidii slioiilil lie made from witlioiit inwards aloii;; the siipra- 
orliital arch, iiist below the eyelirow. to a point witliin the puncture; 
a flap shouhl be turncil down, tlio eyeball nentl\ dept(s,sed. and the 
inner wall of the orbit and adjacent "part» tarefuily chippetl away with 
a aniall chisel or >joiifp'. The lneniurrha>!e from the uiiKular vesselrt 
may be tiotiblesome. .Viiy foreijrn body or infe<'tive material is 
thonni^lhlv removed; the dura mater is also inspected. If this be 
lacerated it should Ik- i lioroii;;hly exposed, the dama^'cd part e.xcised. 
and the subjacent In lin caiefully clean.sed with steriliseil .-ialme sohi 
tiou. The cavity is then draiiu-il with sterilised u'aiize. a diainatje 
tube being usetl as well if needful. The dre.ssin«;s are cliat!i;ed daily, 
and if tliere is nmch discharge, hot boracic fomentations may be 

The apparent sli^^htness of these injuries, the tritliii<,' wuuiul owin^' 
to the mobility ot the skin and the .sli<;litness or absence of any 
sub-conjunctival ha'morrha>;e. the wound may appear not to have 
perforated the orbit the period of latency of symptoms, and the 
onset of fatal brain mischief -inevitable, though delay fd. if let alone 
-should always be remembered when dealing with these injuries. 
Especially misleailin^r are those cases in which an instrument has 
slipped under tiie lid. reachin<: the roof of the orbit and the base 
of the skull, leaving, it may be. men ly a patch of ecchymosis im the 

(5) For the rem-md i>f foreign bodu n Jif.siirinij or fractinlii<i llir .sk ull. 
These are rare. e.(f. penknife-blades, pieces of stone, bullets. &c. To 
ensure certainty of complete removal the trephine will usually be 
reipiired. Tlie following case of Professor Nancrede's shows how the 
gravest results may ultimately follow on the overlooking of a small 
piece of knife-blade. The apparent slightness of the injurv. the 
long absence of symptoms, then their sudden onset, the ditHculties 
met with during trephining, the results of promptly meeting them, 
and finally death, due to a hernia cerebri, are all deserving of careful 


J. Y »•». 11>. il int.. iUr K^>iM■l<^m\ M.w|iilal. . ..m|>l'.i"i'>K •'' ■« !'»' 

tonal liH li. ml. 111.' ivmiK of a l.l'.w r iv. .l Iw.. i....nlli« |.r. vi..iiHlv On . Naiiumr« 

thT wmiii.l. in Hi.' •■. iilr.' <.f ..ii iil. . r. ■ i.rr. »| liiiK in iH.silM.n (.. tlir . .ulr.- . .1 • hi- 

l..ft i»>ri.'l<il I..IH'. was fc.iin.l 111. I.i..k. . n.l ..f a kinf.- On l« inx 
(»• w. IIM-.I tli..r..ui!lilv .HUipiis. ll. hill Intl.- ...iiUl If "Wtlc- out IM 'W"'*^' 
<l. ntK ..f til.- alia. k.". XI . |.l tlial a ni.ui hod utrurk him «m the top ul thp h«lrt iio that Ih' l.a.l (..ll. n ..n \m IiuikIh and km-**. Iwil that he had rworMwl hinw.-tt 
aim. Ht«liat..|.v. He miA that he did iu»t. at that time or alfrwanls Ur»- 
cmi^iouKiM-*.. nor had he »ulhn6 from ht-adachi-. Ho did not «-oni|.la.n ..f anv 
pate or uneomtoftabte awwation when th.> knifc-IJadt- "■»«^VV<I- '">' "' "' 
jHftomoon of the Mmc day hr had olight ,«iin« in th«- h.-ad. The foil.>wn«ti <i"v tl'" 
t< in|M n>turf wiw lol \ ami Hli«ht n-tiiial h.V|» n. i»ia wa.n n.>li< . <l. h i-i . (.litcrn. 
iM-i/ s H i ill ii. .xt .lav. iK'ninninjJwith twiU hinnof Hi.- hkIiI arm. lail .s.H.n l« . ..inint| 
«-iu-ral. Til.- lH.i..- was In pliiiud ..v. r Ih.' mniI i.f injury, aii.l Ih.' |«.ili"i[ 1.111..V..I 
"howH a rtlinlit ,|..|,r.sH..n ..f il. imi. r lal.l.'. Tl..' |H.siii..n «hi. li tlic hiMl 
.H'< ui.i.<l ...iil.l I..' «.'nin III.' .I .. . nial.r, tli.r.' Uiiiis an ..|«'iiin({'«l witll 
.l. n.'..' . i. alri. ial lisHU.'. Tli.' .1... nial.'r <li.l n..t ><■,-,» t.. U- ftrngimtwl. and thMB 
.'vi.l.iillv 11" lai.. or tliii.l i. ii.alli it. During tin- iwxt thitf wwk» the titii 
.'.■as,'.!, l-ui ;vn,l.t..Ml^ . .nbral abH«t*»-viz.. temnrnture iiwlMHjrmal. 
,.l..w piiU . liiark.'.! 1... il .liiln. sK K.'t in. The |iatii-nt then dey.-lo|i.-< right 
iHinipl.-gitt ami betamr uiifonwious. Tli.- Nap covering tlw tr.'j.hin.' Iiol.- wa« 
ifHwtwl and wan found to be o.'.upi.'.l l.y the tonne dura iimt. r. lailsalintt slnmKly. 
It waa inci«d and an aapiratiiig iu-.-<ll.' inir<Kl.i..'<l in --.'v. ral pla.'. - l.ui wiihoui 
mircrw. Feeling convinoetl that pus wan pr.'«'nl. I'rof. Ni.n.t..|.' n.^phiiw.l m 
front of and Mow tli.' lirsi <.|K'niii(j. wlii. li was ,.liulilly Ih'IiiihI Hi.' Iissiih' of H..lanil.i. 
B.>for<' th«- »kull wa> .livi<l. <l l>..tli |.iiU' an.l ivspiralion .■.•as.-.l. I la' op' rail. .11 
U-inu rapidly ('onipl.t.<l. Ilif iliira iiial.r was li.r.' iiiiis.-.l willioul r.sull. ^ 
moim-nl pus' was ohscrv. .! to !«' ...iziiiK fr..iii oiif of II"' aspirator piiii. lur. s. .\ knilf 
iH'iiiK pliiiit5.'<l into I h.- Iiiain siil.staiic.'. from on.' I.. I wo oiiii.'.s of pu.s w.-r.- <'^'''2'"'*'™ 
Th.' pata nl r.'viv.'.l afl. r \ iiforous an.l prol..iit.'.'.l arlili. ial r. spiration. The next 
.lav a li. rnia .•. r. l.ri as larp' a- a walnut was protriuliiiK from tlx- wouwJ m the dura 
inat. r. I liis in. r. as. .1 in si/,.', an.l l.^.k.- down, the ,iatient dying four day* later. 
At th.' autoi«v th.' l. ft purietal IoIh' ('(mt.iiWHl an enornwua ab«!«» wvity whwh 
had deatioyed the greater portion of the URier pwrt of the l. ft hemiaphere. 

TSirBuno* ni reAonmiD gKuix (Figs, no, 120) 

The scalp having been uhaved and thoroiisihly »'l.>anse(l. the pati.'nt 
anamthetised with C.E. or chloroform.- unlesw u coiiditioii of un- 
consciousness renders this unnetessary ; the head is supporto.i on phiuI 
lia.'s iit u conv.'iii.'iit hcijiht. The fracture is next exposcil. tin- o kl- 
fa.shionod cni.'ial. T- or Y 'sliaped incisions being now. whon p<)s.sil)lc 
.'.•placed bv the semilunar flap of Sir V. Horsl.-y. The flap 8h«>uld be 
so arranged as to fullv expo.s.- tli.> li.'l.l of op.Tatioii on the .skull. Its 

base is usiiallv below to ensure a ^ 1 l.l< The nieismn go.'s 

down to the 'bone, and the pericranium is divided, witii the flap rai.sed 
cleaiilv and uniformlv with an elevator. If it be nee.lful t.. operate 
throui'h the temporal muscle, its fibres must be sufhciently severed 
and rai.seil with the flaps, it being somewhat more difficidt to separate 

' It has Wn aln a.Iv >latp<l that in many . a-- .l. pr.'ssi .l fra. tiir. s aft. r . xiHisure 
of the frav'nu' a pair of ,lr.•s^i.,^.for.•.'ps an.l an .'l.-vator may <lo all lliat Is r''\""t^- 
When- n.. Uvphin.- i> ..I han.l. a .hi>. l a.M mall. t ^ l.o n-" 1. .\s s...... as 111,' .lura 

is .'XiM.s.'.l. 111.' pr. r . n.iiial , IiIm I with a shoul.U-r ( Ki^. iil) is always t.. 1..- Iiri-ft'trcd. Ih.' tri phii'.' il-c If IS not alwav > n. ,'.l.'.l sh..uld be clearly umU-rstoo<l. a» it w pn'toble 
that elevation uf frauiii. nts might oft. ii most wisely have been iK-rformed had it not been 
for the abrence of a »iJecialin«trument, wrongly suppoHcd to b<> 

* These antpsthetirs arr to h- pnfem-d in case« of tn-phinmi.'. on aciiiiiil ..t tli. 
irr.'ater excitement and .'.mvestiim whieh are usually as,oeial.'<l with . Ilier. Hut wli.'neier 
it is iK)s.sjl,h.. ami esp.-ciallv wh.'.i the pulse an.l hn all.iiii: ar.' falling', ana'stlu li. s should 
I..' .lisiieiisetl with. W h. r.: th. re is anv ten.l.'n.y t.. iln.wsiness or eoiim " tli.- aiiasllietwi 
sh.-ul.l attempt to M.ure an analuesi.' rather than a true answthetio »tate (tf«w»« 
Anoeslhelica and thtir Administralioii. p. 54). 

I nAlTl KK Ol TlIK SKIM. 2^5 

tin* peri*^!*'!!!!! hiTc. Ol) ( ouiit of itx thiiintiw in thin region, ami mw 
intinmtt' uillifHion to the siil.jiK . nt Imhi.'s ' In ictlft tin;; tIk- Ha|rt. 
freo hii'inorrhap- is m-ailv iil\Mi\.s nu t \Mtli i s|»m imIIv in tin- i .i^'' ol tin- 
chief Buperttfiai trunks and tin- dc.-|) t.-ni| .iii.ii''.s, Imi iln^ i- 

f»roiiiptly and easily urrettti-il In- tin- usr ol S|m ii( . r U . lls's <.i Lan. 
itrcepH. 'which act an lil«it UW'ful n lrai tors, lakmjf u|i lait iitlli' romn 
while at the same time they arrest the ha-iiiorrlwtte. It is always dittit ult . 
owing t<» the density of the tissues, to take up the vt«ssels neatly hen*. 
It is (juite |>crnn.ssil)l.'. fs[>e(ial)v ni urjrent cases, tti take up the whole 
thickness of the tiap. OwintJ to its vascularity it will not .shumh. Xo 
HUtures should be inserted just at those spots where the (oweps have 

Fii;. IIH. Miikka's i'lnm|iH f<'r i imtrnl i f liii iiii.rili;it.'c from the ~i .\\\> dining 
trephining. On the right in ligiired the (urci'iM fur iiii>ni|>uliiting thi- i'liim|w. 

been applied. Another excellent niethcMl of tenijiorarily contP»Uii»>{ 
hiemorrhaffe from the scalp in is by the uw of Makka's 
clamps (Fifi. Wr^). < >ne Made ul each ( lamp has a sharp jioinf 
which is pushed between the .soft parts of the bone: the other lihide 
is on the surface of the scalp. The veswls are thus (irmly compressed. 
If bleeding continues from any crack in the bone which may now 
\» found, it will only cease on the elevation of the frajtment. or on 
the exposure of. and the dealing with any subiacent ch>t. The 
fracture l)ein<r now in view, if it be found im|M)ssible to introduce an 
elevati • stronj; dressinj; or se(|uestrum-forceps. even after siwinir olf 
anv projectili^i aiijfie of Imne. tlie surireoii decide where to |>lace 
his trephine. In doinj; so. lie must a spot, if pn.ssiltle. clear of 
a sinus (-wp p. '2o2) or large branch of the middle meningeal artery {nee 
p. 273).* and one which will at the same time sup|M)rt firmly the pressure 
neeth'd in tli \v<>ri^lll<; of the trephine. Thus the pin and greater part 
of tiie tiephii\e-( rown are ])la(ed on sound bone (Fig. I lit)- while a .small 
part of tiic ticpliiue usually overhangs a de])ressed fragment. Rut 
if the surgeon fears that the fragments are in contact with the dura 
mater, and perhaps injuring it. and that the jarring movement of the 
trephine coming in contact with one may be pernicious, he will so place 
his trephine tl»t it rests entirely on sound bone, any intervening ridge 
being easily cut away. 

' The prcatcr thickiu'ss (if the soft |)art» which will here form thi- licntri.'i will, in a 
meiLsiire, make up f(ir the iliHiruity in iire-scrving the iM'riostoiini. 

* If it is really needful to tn-j)hine over one of these ves.t«'U the remarks at p. 2*H>. 
will (how how the hieoKwrhi^ ahottk} be met. 


A snot hfiiifl thus clioscn. ii tivpliiiic of ii!)out one iiuli in dianu'ter 
is takon with the rcntn'-iiin protnuh-d for iihoiit a tciitii of an inch, 
and firmlv Hxed in this position, th«' tr.'phim- l»Mn-: so jriaspnl in tin- 
hand that the indox finger steadies th.' <onti( -i)ni scivw wh. ii llu' Im.ih- 
is .'iit.'ivd. The instrument is now firmly applied to the Ixme. the 
centre-pin being bored inwards, and as soon as the teeth feel the btine 

J'li; 1 lit A shows a dt'imwM-tl '• Kiilli r " fnicturc in thi- ri):ht iinrictal Imnf. 
'1 lii- ilutti'd cinU- inakatt-H thf di^c in 1" r. nmv c .1 l.y th<- tn-pliiiw-. B, 'I hf 
ha* U-t-n removid and thr il« |irt >^. . I fi iiiim nt> arc k-vt-n-d into iMwitiim liy 
■nraliK of an i li valnr. 

the trephine is worio-il from i>-fl I" rij-'lit anil I lien from i i<;lit to left, 
care beiiijr taken to e.xeit e(|iial pies.suiv in both diiectioiis. While 
til"' lirst <;roove is bein;; cut. the movements of the tiephine must be 
light and^quiik. hut without jerking, the tendeiu v of the instrument 
to «lip being met by steady bearing on the centre-pin. and by keeping 
the left foretinger at lirst on the bone chKse to the trephine. 

As soon as a groove sufficient to keej) the trephine steady has Imm-ii 
c;it. the pin is drawn and llieiv fixed. Thi' lolatorv moveiiieiits 
alternating from side to side a:e now continued, care being taken to 
bear as cvinly as {HMwible on every part of the circle, till the diploe ' 

Thi* ii" alwnt «>r defieipnt in carlv lifo and in the a(te«l. AUo, over a larpi- part of 
th- It (iiamouB Ih iH' amt 'ii »h<- «. < ipiul fowse, dijiltM' in wv«T met with. 


(if this is present) is reached. This is known by the easier working of 
the instrunu'iit and by thi' softer sound. On tlic living Ixxlv at least, 
owin^ to the oozin;< front the vaseuiar parts around, the l)lood-.stuinin<; 
of tlic l)oiu>-du8t (kscribtHl as taking place at this stage is liable to be 

Throughout the operation, but fspccially now as the tliiniier table 
is being reached, every care be taken to keep the circle of equal 
depth : ( I ) By pn>s8ing on the saw evenly ; (2) by making it bite in 
e<{ually from right to left and from left to right ; (."5) by remembering 
that, owing to the skull bein<; spheroidal in slui|ie. it is im]>ossible, 
witiiout the i.'ieatest care, to keep the 
<;r(>()ve (if eijuai depth all round : ( Ij l)y 
bearing in mind that while the average 
thickness of the adult skull is one-tifth 
of an inch, the thickness varies so nmch 
that it is almost always greater at i>ne 
part of a trephine-circle than at another. 

'riilis at frei|uent intervals the Hat Fi<;. 120. .\. .Siitiun of » ili-|>n-KM'il 
end of a .sterilised t rephine prnbe nnust '««««""■■ Kl. v«ti.m ..f the il.- 

e carefully mtroduced at dillen-iit ;,,,.„„„ri„,„,,,„.,.,,,hV..,mh .Hf, |.him- 
spots, and when the circle is foimd to .i|M-iiiiiv'. 
be deepiT <m one side (still more if it is 

perforated) the trej)hine must be slanttnl so that its teeth are only cutting 
on that part of the groove which is still .«halh)W. When the groove has 
been made sufliciently <leep. ai;(i <.nefiil examination tiixls three or four 
pointsof penetration, the bone may be renio' ed by insertiii};tlieelevat<trat 
the deepest part of the groove and lifting up the disc of bone by (are- 
fully making a fulcrum of tlu sound bone oi of a linizcr. .\n elevator 
is then gently insimiated between the (lepre.s.sed bone and the dura 
mater, and the depressed area levered into p«siti»>n. Any lo«»se frag- 
ments are removed and preserveil in sterilisetl saline solution. If profuse 
ha>morrhai:e occur on raising either the disc of bone or a (lepressed 
fragnxMit. it will pro'iably come either from a branch of the mi. Idle 
meningeal artery or from a sinus. The treatment of the foriiic:- is 
given at p. Hht : in the latter case pressure should be at once applie I 
by means of a pledget of sterilised gau/.e : if this has to be left In silii 
beneath an edge of 'jone to control the bh>eding, a ligature of sterilised 
silk or catgut should be fastened on to it. to s«H'ure its withdrawal in 
ab<mt three days" time (mc i>. 2'>'2). 

In the of a punctured fracture, a full-sized indi trepliiae should 
be applied, .so as to remove the outer table around the immediate nei).di- 
bourhood of the puncture, and thus expose freely the damage to the 
inner table. 

If after removing a crowei of bone more riK)m is still re(piire<l. this 
may Im* obtained either by taking out a second crown close by. ami 
joininj; the two, or by the use if a lley's saw or llie forceps of l)e Vitbiss 
(.vcc p. '.\\'2). or of llotfman's forceps, or Lane's skull lorceps. 

Sufficient drainage must be provided in wIik li ii (|uire 
it. e.ij. where infection is present, i r wheic a large cavity is left under 
the flap, in which fluid will collet.. .\ny drainag(>-tube used should 
be l)ron<:lit througli the lowest part of the flap, by puncture if iH-edful, 
and stitched I • the skin. 

Where it has been needful to remove bone extewively the queirtkm 

SCKlil-.KV I 17 


will arise as to tho best moans of diniinishinf! the gap. In many . as.-s 
thf trephi.i.-ciown or bono frafrmonts. so Ion;; as these are n..t too 
BDiall. unito roadilv if ti.-v havo boon kopt in a lu.t stonlo sahne solu- 
tion, tho tomnoratiiro of «i.ioh has b.'on ruMintan.od. In many cases, 
often %vhon thoir survival is most .losiro.l. thoy fail to unito. 1 hov cannot 
be used in compound fractures, whoro thoy aro po.hai.s mf.-ctod ; or in 
cases where the dura mater and brain havo b. en u.jurod and any . avit) 
or irroiiular surface e.xists. In cases of trephining for traumatic q.i opsy 
thoir ronlacemont woul.l bo injudicious, it bemg here desirable to leave 
a .safotv- valve for tho relief of future varying tensum. Where the 
scalp has been extensivelv destroyed the surgeon may. if the patient s 
condition permit of it, di'miniah or close the gap by means of one or 

more pedunculated flaps. 

ButTas a rale, this will be left to u later sta-o. (ierman .urf;o ons. 
Kiinig and Muller. have advised that such flaps, for the bettor protection 
of the brain, should bo raised with periosteum and the outer table, tn 
lu.ldin.T tho chisel l.ori/.ontallv. This is a s.-vere operation, and onlv 
po.s..ibU. where tho bone is well .levolope.l. It cannot be emplo.vo. 
in children owing to the non-dovolopinont of tli. aipiuo. Another method 
is the employment of grafts of .local. iticd b...,.' l.v Somi. 
Here all M-ar tissue and tho od^'os ..f the adja.. Mt l.-m,; must 1." < "ni- 
ulotelv removed, so that the graft will Ht accuratolv w.tli th.- .avitios 
of the .iiploo round the margin of the fracture. The vM..ft must be 
covore<l with tho scalp, bv a pedancttlirted flap, tf needful, and strict 
asepis is necessary for success. ^. . ^ j_ • ..ji^ «, 

The above remaAs refer to cesrfitiona a* fw ii»me*««e or 

^™The^ SSSSi^ill be anwHigst tho inti-mwHliato ,.r .s. . .m.h.. , - on- 
ditions which inav suggest trephining soaw days ..r wet'ks attc .n 
iniurv to the skull when' there is no definite widence of fractiiic l.ons 
continuo.1 un.nns. u.usn. ^ as when this \^ over twenty-four Im.u«. 
no other cans.- than r\u- mju.v boinjr present. Convnlmnns. wpeemHv 
if localised and ass..c,at..l w,rh apl,asia. I'a.alvsis. espcial Iv if marked 
and occurring in adults. Dennis' nfers to a case o) .^chdd who MB 
on the pavement fi«tn a ^rd story, snntftining an miwrted tmetvm 
of the parietal bone. 

Th- n.M.ptt— >.>tli.-,..,... U> |„.„h,r, lu nu|.l, «m of tin- ' 'I'l;'^'''' .''j^ 
,k.-,. .-..nm. IX-imiK «. iiianil.nlat. ,1 tl.. >M|r. nf ,1,.- l. a.l as to . aus.- .h,- in.l. ntat«« 
:.„! ,o ..isa,,,.-a,. A.s Jk.u as Ik,,,.. „ '"^^^ZAZ^Z^ 
, l„l,l ,Lss. .1 ..I om . fi^.m deep coma into comfA-te i-onaeiownw*, »nd the lieimt>i<^ 
iitHtantly (li-a|iiH'an'il. 

The possibilitv of a linear fracture causing a dopre.ssion of the inner 
table has often bcMi overlooked. MesBPi. Shield and Shaw report" an 
interesting ca.- ■ of this kind. 

The i«tient. a healthy inun. ivt. 30. HUHtnin.-.! a «alp wonii.l m U,. I ft fnmtal 
regioii. NofBMJtiire wu» found, and the man ■■.m\hw<\ to In . I to, a .hurt timy 

foTconoUHsion. He wm. iK-rf.-ctly well tor m„„. «e,k>. l^ut al '■ |tl> ■ 

the iniurv hr iH Hai. to Muffer from juiin in tin- Im ad. lo^s ,.f i"' in..i \ .>ih mi.I.I.h 
buwtH <>f"pa>Ni"ii. n< Kradimllv reached a coiLlEti.,!, of .Ir.ii. 11,. rv U iu u; 
hiHforv of aleoliol,.- ex.v.s or syphilid, tl,. .v„,|.to„,- a,,),, an .l , '''7 
to tla- i.Ourv. .>;l,aw tre|.l„.,.-l al tl„ . „t ,„j.,n a„.i • ,,„,d a t.eale.l ,. ■. r 
fracture with a .ieim .-Mo., ..f il,. , tal,l.'. II,. ..|.eral,.,i. «a- „.= =-.»<liat. l.v 
foUowwl l.yiimoHt mark, , I .|,n.s. i„. iU. Thp|ia'i, ,.t iilni.iately re,-,,s. re.l. 
» .Ufrf.A'fif»,Marih Ji. IWi. ' / '■<'■ ^••l'^■,.Hrv 14, iW.i. 


It is os|x'fially under the tliitknosfi of flu t^'iupural tnutK-k', itwM 
sw(il!«>ii with cxtravasated bliKNi, and the mit partti ovrr it hnum ' 4 and 
tender, and thus intt'rfering witli tlie accuracy of diufinoHis. that tbc 
existence of a depresHed fracture niu«t In- renieiiil)ere<t, when an altti<Kil 
mental condition, liiiliu-ss, &c., ami, if an the teit aide, mfimm, gup cTVwtu 
.sonic time iifter an injury. 

Trauniatic ccrfbriil al).s(c.>;s L'tili Sii|ij.uiano!i hftwcfn tin- Ixm*- 
and the dura mater, which i.s considered in the ne.\t .s^Ttion. i'lm^n of 
IntMnorrhagic paehy-ineiiinfcitiD. whii-b iMtuMtmaHy ft4k>w on trauia ami 
give rise to pressure sympttmis «fck4 demMid (^pam^m ■rinrfemwe. 



While tlM3 mode of using the trepiaae h«ri^ im ma i»y diiier itmm 
tfaail sIre*cK' giwn, a few practical rewKrkx wB fee mmtte on this ni«*rr 
tmpcwtant comlition. 

(^rative inteifereiu hi'li'. wlill.' |i-^s f|iM|ii.-MtK- called lor. owiiis 
to tile improv cnieiit.s n| inodein sur'.'"'i\ i'S|«'cii(lh tlie aiitise|itii- triMi- 
ment of scalp wmniils. has alsn liccn sm .suti-vHttful than it would app«-;ii 
to have l(ccri a Imndrcd mmis ami when P»*t. <)rw tbe attention ot 
surgeous to the need of trephining wbeii pus was present iiiirogd iat^'lv 
benmth the skufl. For while Pott, in his day. savwl ftve out «f »^|fht 
of in wliicli ln' t icpliiiii'd. surjji'oiis of later da -;, when tliev 
have trephincil. have hi'cii iisiiallv Im tiled l)v tin' co-fxistence nl pva'inia 
owihL' to an nif.'; live (.,ifo-ni\ I'iit - .uid |)hlcl(iris of the veins of the 
diploe. or it till- ii>ninon.s i-ompii< ;j.Tion lie absent, by tiniiing the col- 
lectimi of pus imt Nx-alised hetwet-* the hone and dwB aster or, U m* 
localised, couil)UM>d mtk SH^urative arachnitis also. 

WlWB it is renit imbLMJO that pus tines not f»»mi lietwew the h<w** 
and mater without a previou.s s»»ir«' of infej'tive osteitis ainl plili'liitis 
of til'' \ ''ins of the dipl(M>. it will ri'ii»»ih i>e understood iiow casiiv. d the 
■.■.iiiiiiil in- cont^nunatt'd. inli'itive osti'o-myelitis and phh>bitis. wiA 
the inevitalili' n—*»lt >ii pvicniia. will |i>ii<M\. 

MicatioDS of tkt formation of pus between tbe bone and dura mater : 
MHliMl ol trsHiniBK. There will usually be a history of injury to the 
hMi with daiTWce nf sf>me kind to the outer table. Thus then* is fn'- 
<{Hmtly a scalp wound e.\|Misini.' the |h i u raniiini olti n u|)i'nini; this up 
though this niav have escaped ob.servation at the time: i" i .isinnallv the 
bone itself i" laid bare ^>v fin iiijur\ .•^onietinies. Iiowever. ("infusion of 
the soft tissues and fli.- pericianiuin alone nwy be the starting'- point of n 
S(>p^- o.steo-myelitis without any open woand. fiither mm or later on. 
the wound be<'ome« infecttti After a van-ing pniod, ttiHwUy in the 
ciHtrse of the secowl week after the itijurv fidirtng which ]M>rioH (h^nite 
svntptotns a IV often absent), headache, fii'tfubic-- ' .ois. m v.,ini«tMir 
s» !<■ ;:radually followed bv dr-.wsincs- <t. liiiiHii. I \. . Iiih;.'- ■ .iS»iniis. 
paridysis. cdnwi :iiid -i .it ii 

. >'s (iiiiush of syniptoms about the rivditji -ir tenth inv nmv Im' 
accompanied by evidence of pya>niia. viz. rifzors |ol|i»wwl «a jiweaBinp. 
a jactitating temppsitwe |i«»^««»ve «w«ciation art** affectiotj!« of 
viscera and joints. amon<;st which pi<-i»f<> pfi«-M4iFt<iirti< iv <.oe of the iiiost 
frejiuent and ;,'ia\ e. 

The surgeon wlio is wati hubi^ .t^. » his kti**! and who i» also 

omnAmmm m ifm i«ad and nfx k 

nut WMrindlul ..f wlMt Ims hai-iMK-a aiul what 18 liable to be going on- 

S #ai«in^ "f tlu. .lipl..K- v..,ns. tl... ..xt.-ns...n t.. tlu' .nn.-r table 

s mp^at... this deep-Beatetl inHanu.mtion only t..., .vacl> t 

:;"!7"o th.. anu-hn.^1 and thus become a drifum- '«."-""^" - 
tin.l It a man... ..f .nu. h dim« ultv to answer the ""J^, ' 

Z mis,ln..| l.s tl... .as., a hop-less a»e the .ntra- 

cmnia r. Lt,..., of pus I... a l... a!iz...l ..n- and uncomplicted wel - 
hemipla'ia and tlu^ al>s..n.-.. ..I ,.va.„n.. sy«.,,t..n.s will t-all 

for n;,>hini«,!. On the oth.- han.l paralvs.s. -'bstUH- or 
, L,l..„. .....l.-pt (om, e««Vttl««.»s. .mtab.l.ty. an. ..s,.... m1 

' ' of ,MV..Iv.>n«mt of inm^ at tfa.- base, wdl all pomt to 

m..u.n.Mtis xvhirh will ^ow it8.4f as a dtffaw taper of p«b 

aiiv ..villi 
that f.irni "I 

aaul Ivninh "V.-r ..n.. sill.. ..I th.. aiai-iinoid. . 

E.,uaHv (KHnt.n, ... . i.tai ,ss„.. will 1..- tl... svn.pto.ns of 

lOreadv allu.l.Mt to an.l n ln"-' no fiirtl...| m.-iition iu-r.'. 

WL don., ni tl-^.. ' VVlH-n- tl... ..vu1...k-.. ... ............ 

is un.loubt^. .if s.H«e d»v« st«Mdi..ji. wher.. tlu- l.a.s !..•. 

E^,r:"k,..i ,„ vi,..,-.. .t .s replaced by i>««p^-^-, ;:7:tx:ib^^^^ 

■'•"s^i a . , f .•.r-.-.-uKtui' p^ .«— 1« looked upm as equally 

Sv'^':^ ruJ.:^ ..In. n. pya-nda resjdtin, 

ment ..( th.'s.- tasos is. of course. pr,^-entive. i.e. every scalp wound 
ZJ. l. -l as..pti.' a...l k..,rs., from the hrst^ however 

. Z 1. .s....n,s to 1.... But. as this pn.,.auti.,n .s not always take and 

?s .KTasu.nallv i„.p..ssil.l... tho c.n.liti.... ..I tl... p-...ra,..un. an-l tlw 

2uld be eV-a .'arli..r. at tl,.- v..n Urst -''-'^^^^if 
Instead of treating such a cas.. as a sp.., uil result .. " J" > 

a i.d w...ti...' for...i.le.ueof pus between the lK>ne and diau mat.-,, n . 
i u d -al with it as we flo with osteitis aud iK-r.ost.t.s e sewl ere . 

av that i.i . as.-s .,f this ki,.d where there « reason to beheye 
hi The b me has been ...jure.l, esp.-eially if there b.- anv doubt as to 
t: c dition of the w..u!..l th.ou.h.n.t the sur,....n sluu.ld on the 

verv first appearance of, ,r,-.tal,.l.ty, ' * 

Sness exiSore the wound. Any grai.ulat...ns will ^rn 1...- v 
" " t-;,?lstill. A piece of bone will probably 1.;- bar., an.l perha . 
soft tl,.- p.-rHra.,ium infiltmtcd and separat.n|j. l b' w x.le a ea 
Zm lu. . IS alV.......! sl,....l.l b.- This .s J""*-' "^'»"^"'.^' 

Se!m tal.l.. an.l .-.v,, tl.,- -llpl.-e wit!, a ,,.u,.. or ch.sel. Whe|^ver 
SSion .itl. pus o\ U...1U.., is pn-s.-n.. » 
must be followed up. H necessa.v .h.- bo,... ,..,.st ' ' 

with a trephine and Hoffman's f.-,. . I he state of th.- .b ra i„a r 
, t a;.-.,.ai„.-.l in every case where or pns is pres. nt, Vn 
n i ua.'e n.ust I,.- s.-cur.-.l bV removing the wh..le th.ckn*H«, -.1 tl,. 1... ne 
u V h lis.-as...l .,..--..b-a„.-. as w, as ,„.>sihle. V\ here tl,.- pat .m^ s 
condit on a.)i,H..> of i. an.l wh.-.v this sf -p m.luat.-d bv th.- -'"I'l^ «; 
an7of the s.n.ises that are a.ijH. e,.t t.. the an-a u op. r^tn... an. wh c 
be reached should be explored and, .f i.-fected. treated on the 


civpn at p. 350. Tn anv caae all infoctivo firanulatinii tissue must b.- 
rciunv.Ml and fr.-r .Iraiiiai;.' must ho ])n)vUlp»l. Tho_p«Mwible co-oxistfiiee 
of a ccrcliral alisccss nmst not be foijiottni (we p. 254). 

Th.' alx.v.' .l.' on the lixc.l c.nviftion that tr.-i)lnmnf;. m caroful an.l witli diu- precautions, is not in it.s.-lf a <hm-:.Tous ..p.-ratioii. 
and on the fuc-t. whidi is h.-vond dispute, that, if th.'s.- <a.s.-s an- U;lt 
till hemiplejiia aawmnces the existenc- of mtraciamal pus. th.-v \m1I. 
too often, 1)0 loft t.« long. a« this waitintj will giv.- tnn.' for tho on.set 
of pya>mic infection anil km the arachnoitl to be involvtHl m the 
intlammation. , 

The op.Mati.)M of tr.'phminj; h.Mv will in no way difTor from that 
alreadv .l.-senbe.l. I'us w.-llinj; up from th.' .iij.loe. or a f.i'tid comlitKm 
of this, is (miinousiv .suggwtivo of miiM'ii.lini: |)ya'miii. If su. h .i « on- 
dition lie nrw»ent, the Immk- shouhl l)e fr.'elv rem..v.'.l an.! .lisml.eted 
as&r as peMiHe; but the outlook, from th.' proi)abl.' extension ol the 
thciMttbt to the simw's. is n verv dark one. If pus be present iK-tweoii 
the bono and the .liira mater, it nmst bo thomngHy evacu8te<l and 
fredv .Iniin.'.i ' Th.' .ondition of tli.' .luia mater should alwavK be 
examined, wli.'tli.'r pus I..' f..mid siiix-rlu ial to it or m.. If it pulsate 

freelv and be natural in app.'araiie.'. n.-tlimi.' mmm.- n 1 h>' don.-. If. 

on the other hand, it btdfio into the tr.'phiii." hoi.' an.l .lo.'s not ])ulsate. 
it shftaM be puBctared. this periiaps ;;iviiij: v.'iit to a j.'t ol piiruh-nt 
faid from th.' arachnoid cavity. If the arachnoid is seen to b«' covere. 
with lvmi>li this is of tho gravest omen. More biwe nwwt be r.'inov.'d 
or a s.'con.l tivphiiw .lis.- r.'m..v.'.i at tlu' most .U'lMflident part., the ilura 
inater a<;ain op.'u.'d liere. and irri^jation emplov.'.l. 

TbeloUowii - i-a.s.'s are fjcMnl examples of this most .lanizeious .-on- 
dition of osteitis of tho cranium and it-* .s.'.|U."la' an.l .■..mpli' at ions : 
The first caw, one of Mr. Ilutihinsons. show- much aia.hnitis an. 
n.) .'.'ii.Mal pva-mic infection. Th.' s.'cond shows both arachnitis and 
pyaemia coiiibiiiod. In both pus was present between the Iwrne and 
the dura inater, 

K S, ii't* 10. was M.lM.ilt.'.l. .Iiilv int.. tin- I...I1.I.1M ILi-pit .1 . xl.wiy.- 

Iiwmtion of th.' sciil|. .m tli.- I. ft >uh: la.Mrii: lui.- tl..- pip. !,,! Lor,-. Dm.iiK th.' 
tirBt few .Imvs li.- s. . ni. <l I.. I... .l.iiiiii w. ll. .Inly -'r. ; l'...n.' a~ hn- •■ ■ ii.hii \»rr,- 

i« e.xi...s. .l I.I .liv ,.l...v.. II... I. fl .-.■.r. .Ink : A M , ■ .,,1: mu.m : n-.t 

RraluilalinK. -lalv :!l : \ . i.v r. sll. ss. I s.- .11 lii> iuril - .t tini. s .,ut 'I-; i'-f' """-* 
iM-tter than th.- riL'lil. AiiL'usI I : Tin -UuH «.is livplii„..| 111 th.' im.l.lle of th" 
exiK.s. .l Im.ii.' m. li. < .il"'V.' lli.' I. tl . ,.r. Tli.- .Iiiia r was .• with 

wilow lvm|,li. I'll! iiiilsai.-.! fi.-.K. <»n .iittiiig tbnm«h it alMmt .J «f thiii 
ir.inil. iil' lliii.l . x ai.. .!. 'i ;!-' ..ra. liiioi.l was mvm t.i l«' .■ov.'re.l With lyiiil>ll. 
Aiiun I -1 : I II. !<• is still paralvsis ..f tli.- riwlit hand. \Vh«-ii tli.' brahi. whwh Iml^tL 
iiiiUaliii r. int.. 111.- w.)mi(l WHS l«iok. pus in lonsidirahle f|imntity ewajMl til. .iia.-lm.M.l .-avitv, lk-»t* t.x.k |>la<-e on AhlmisI :t. Tl»- .mhi.- aioiin.! tla- 
ti. |.|.iii.- a|«-rtur.- was .li'v and (ir<-<-n. On the li ft si.K 111.- a.a. lm.n.l wis ■ .«\.;i<d 
wiUi a thiek detmsit of iiurilUllt Iviiiph. w liil- .m lli. imlil si.l.- .1 v i< I'- 'iial. Hi.- 
MiiHTiorlongittMHtialsinuxcntitain.-.l iiiiiif..nii Ihn.l 'I h' skull at ili.^M al ..I iii.|m.\ dis. <,l.(iiiTd s>v.-r an .-xtffit iilnuiKt an lar(£.- as th.- |wfii> "f tlu- liaiiil : a.lja.-. iit t.> 
it «. r.- ..tli. r |«il. li.-s. tfi.-.-nish-yeBow. and non-vnwmli^. Then^ wm- no iiya'mie 
al.s. i'ss.'s ill aii\ of I In- \ is<-.'ra. 

K. S.. a i. 'lo. was ndmill..! iiil.' <.ii\- ll.-inlal iiii.l. r Mi' M. Moww' <m 
.lai.uaiy L':.'. 1^77. \miI. a -.-ali. ni.iMi.l Imir 111. Ii, i..iiL'. i \|.msim>! ill.- ri|Iht parii-litl 
Im.ii.-. 'Th.' ili- i.aiL'. 1...11I1- .ll. ii-iv. .,11.1 . i\.;i" I ..I III,- M'alp M-t 111. ''!"' 
|H,„- III.- .11(11.- MUliI |.aii.-lal l-.,ii. ■ -p.-.l ■■wn t-' I" sHmnlmit! "f tlH' 

I hi III,-,-, a-.-. ...1,1 ill f.1,-1. Ill -ii:.- II. -.'I, mill- • »!■■ n-tli, - li-, lia 1 -j- a, ,- 
ll<itlMirtti'it f.)mc!»t» (ri-<iii.-nll> ,-lmii«i->l. an- iir.-l,'ial.|.- ^ .livssiii..'- ,-liaiii;<-.Ui-^ 



licriciunium. Inewiaiui wrre mwie wheru npctlfnl. drninaRp ttilNH intriHluccd, nml 
ill a few d»y» the cryBipelaii had imbitkjwl iinil I lir woimil wux nwiff . Fi-I)riiarv 1 1 : 
Sho had a rigor for the fiiwt fimc>. Fi-brimiv l:i : '\'\,r triii|>< ratiirr was II14 ; thi n- 
was siimi- jiaralysiK of thc> Mt nkk- of the fiUf ukI the left liinlw. Ft'briiarj- l"> : 
Tlic li<-ini|)lciiia" li<>coiiiin(j niorp mnrk«Hl the skull was tn-|ihiii<-(l alKtiit one inch 
iiIk)vc iIic \inht |iarirtal <'iiiiii<'iUT. I'us WiS foiiiul in the dilJoc. (hi ri-inoviiig 
tilt! iWsr of Ihiiii'. alKiiit -j of tliirk. fcal. (fi'ci'iiisli pus wclU-d up. The iiiiKT 
surface of the iMHir Was iiiutili. the dura inalir, wliirli i'<iiTi'S|M>iid('d to it. I»iii(» 
foviTcd Willi velve ty (;iaiiiilal ions. As llie dura liiater did not pulsate it was 
puni'tiired lint witlioul result. 'I'lie jial ieiit lieeanie more ion.s<M(ius after the o|K'ra- 
tlon. lull sunn relapsed into a .-ein'-eonseious stiite. Convul.sivi' wizuroM of all tlio 
linilw. with twitehiiiKS of iHitli side^t of the faee. then set ill. and cviltiliwd until thp 
imtit'iit'M death on Fchruary 17. 'I'hc |Mrietat bono wan in a necrotic condition for 
a eoiiMidenihle area, the dipliH' h. iiig gnvn and olTtwive. Tht* |mii Meemed to have 
drained from the extra-dural H{'4tct'. but tliw wan Hiippurative araehnitii* over the 
right hemisplwrc. n-aohing to tiie falx in one din-elion and lowimls the haw in the 
other. There were nunienius pya'tnie abscesses in llie linics and liver. 

In tilt' foilowiiio Sir W. Macl-jWi'ii ' wu.s iiiotc fiirtiiiiiit<'. The 
CHse was niic of ('.Ktra-iliiiiil .si||i|>iiiat ion with pacliyiiit'iiiiiijitis. t'.xliihitiiio 
Pott's jHitTy tumour. " uud orijjiiiatinj; in infective Imiisiii}; of the 
8cal|» unci (leep«>r tis,sue8, but here the pafhvmeiiingitis was fortunately 

limited and pyn'inia ali.sent. 

I. I{.. a t. I.'), reei ived from the shaft of a cart, a severe blow on the left siile of 
tlie vertex, alioiit all iiieli from the mid line. He was siiliseipiently able to Wf>rk for 
II week without feeling anything wrong except xlight |iain ut the Keat of injury. 
Later on lie felt feveriHh, tite pain, which wax of a dull character, iuoreaaed, and wa« 
aceoiiiiKUiied by occanional sharp ittalw over the vertex. He alno had grt^it head- 
ache and immtration. There was a distinct putTy tumour over the seat of the 
injury. The Hwelhng. the (intient declared. ap|)e.ired thrive weeks after the accident 
and after it formed he had .some relief from the pain. Tlie primary swelling from- 
the bruising had subsided snmi' weeks Ufure tli<' piilly swelling apjH'are*!. On 
incision the skull was fuuml bare, a small ipiantity of semi-purulent exudation 
bathing the bone. Tlie diplne was lilled with granulation ti.ssue. which ciaiUI iMt 
traced ill small |H>rtions |ieiietiatiiig llie biiiie. both llinnigli the external and almost 
through the internal table nf the skull, wlneh was daik in <iiloiir. Ilelw.en the plate and llie dura there was a eonsiderabh' layer of freshly formed granula- 
tion tissue, bathed in purulent pxudatiun. The patieiit'a iiymptonw quickly cleared 
up after tlie o|H iatioii. ' 


(Fiffs. 121, m) 

IndicatioM. N\ hen a parent, after twvwiving an iii}(Ky the head, 

ha.s -!i<>wii s.'iiie of svmptonis ijiveB bph»w. 

It IS iiotiwuith\ tl, it the iiijurk' and iMMMimt of violetice vary 
extremely. Wkd* u»osl freij-'ently iwrktUii. i» in fafts "ii the head, 
the vifrfenee m«v be pxttwwely .-flight, for example a jiatieiit slipping 
wliiie yoitii; dowiisf ,«irs .i^i strilciiii: (ns head ai^ainst the wall. ,1 Ixiv 
re«c!siii«; a Mow lioin a eriekt-t Imll. or a eliild lia\iiii.' a tiilliiti; tall 
from a swill;;. Floiii 'his liie toliiiw, i;,:.' (. 1 .! ii -lolls uia\ he drawn: 
in) That in i>i severer xtnileiii-e. iacetation 01 rout iisiiih "I the 
brain are only too fe».^»tently eoniplii'Mtion.'*. (h) Whei. he vhi)^m<:<> 
hail been i^^(ht^'r, eit-feit'v ho fri.ctur*' may l»e prt»sent or. if one fw wvwnt, 
it is «»ft«>n «mh' a mere tis.'*ure atfl mav involve t^he internal table only, 
[t is a piiii.f ..( practieai ■ : aii'' 'hil -lighter llie mjiirv the 
l<'->s like|\- :Ht' the .suit ii.ills < < ■ sf„,\\ mix dailiatje rills lias led tl 
some ea ■ V !o tlie injury lii'in^ >.\.i looked 

(1; Intrtml oj contcionsttis^i <n Imidkif. Typicttl^^ tht' injury to the 
' fifaftnir iHteanti the Bhuh anil t^auU Vordt 


head is followed bv the Hvmptoms of cnncuasion : These may but 
sli^'litlv inaikftl aiill .|iiirkiy .lisappcnr. Then, after an interval, during 
which syruptoins may Ih- sli<;ht i»r even al)sent. the patient gradually 
passes into a cDiiilitidii of dcop coma. This interval Ix'twecii the eon- 
cu88ion and the onsi't of coinpiession varies, when |»reseiit. from a few 
minutes to several hours. In about half the cases it is well marked. 
In a second group it is but little marked and may he easily overlooked. 
In a third an<l last set of cases this interval is never present at all owing 
to (I) the presenee of a very larjje ha-iiiorrhage. prfnlueinn eonipression 
symptoms at once : (2) co-i-xistinn depres.sion of bone ; {."<) co-existing 
injurv to the brain : 1 1) ilrnnkemicss of tiie patient. 

(2) CoiKllHon oj the limlm us li> hrmiphi/iii. fHirdhjsis. riijuhlii. <{v. 
Hemiplcjfia. though well marked in a larp- proportion of cases, must 
not be htoked upon as essential, and middle nuMiiiineal hu niorrhajje 
must not be overhniketl liecause hemiplegia is absent, ill-marked, or 
replaced bv some other condition of the limbs. At least the following 
seven conditions of the limbs may be met with in middle meningeal 
ha?morriiaire : 

(a) Hemiple>;ia present and well marked, the lej; or arm. and u.-^iially 
both, when taken up and h't jro. dropping without any resistance. This 
condition is present in pn)bably one-third of the It is n(>te- 
worthy that occasionally the hemiplegia is on the .same side as tiiat 
injured, the extmvasation taking place «in the side opposite to that 

(/<) lfcMii|ilejria present, but little marked. In which 
are not nncHmmon. tin- extravasation may be overlooked. They fall 
into at least two divisions. In one the hemiple<;ia is little mnrketl 
throughout, due. perhaps, to s»mu! |M)wer of accommodation on the 
part «>f the Iwain or to the circulation remaining feeble owinj; to (o- 
e.xistintr shock from the time of injury to the moment of death, in 
another <.aou|> of cuses the hiMnipletria is ill-marked Wause of brief 
duration comiiiL' on as it does in these towards the close. tof<ether 
with coma, fiivin;,' but little wariiinj: and leavini: but short time for 

When then' is any d<mbt as t4i the existence or dei^ree of hemiplegia, 
the following tests viimnM Iw car*>ftttty made use of : whether the patient 
resists on the sur<reoii attemptin<; to move the limlw ; the power of 
the -.Tiisii : th.' result of a ni'edle prick; whether the patient nwvai 
eith.'r of !iis hands, ni which of t^em. wfcen the twnea is careful^ ' 
t(e,iched, or the cilia gently |iulled, 

(c) llenii|)lei;ia prewetit. but teiM|H>rary, A very rare (ondition. 
produced probably by tiw l»»»n Innng aWe to accommodate it.self to 
the pressare of the Hfused Mnml. 

il) Mc\no|'!e'.'iii "r the par.dvsis ir»ore mark«l in one lind) IImmi the 
otlitT While a hii^e ha'iiiurrha'."- ueiier^dlv mak. i.reHsiiri- UjMWi all 
the niotor are.-i. vmi HerL'ni.inn and Kii«nlein pon out ■] ,it the opposite 
am is the part aflietr«'il tirsf mil nioi^. tie i»ranche,s o! ', i. arterv Kavintr 
bwiiiiiii tjuite small b\ the t they rejiefc the centre Un (;)>■ 

If) (teiM*ral {«rajv«4s. .Vnother rare eonditi'i ; tlw e.\»»tener of 
vrkich mav be explaiiu'd by a verv la^fe t .g or the Wt side 
r i;-.div etYu,s«'d an i niakinu pressure throU(.'h th* left »ule of tbe brain, 
upon the rijiht is well— (»r by cu-exiHting e.\-tr»«««»ti«»n int«» the Lffim 


(f) ,\l)sonr(> of nnv paralysis. A very rare conditi{>n and one which 
is. perhaps, due to the hlood ctTused fiiidinR itH way through a fractMre 
in tho skull lieneath tin- .sculp (.w footnote, p. 21;*)). Anrither explana- 
tion mnv l)e that the clot i.s posterior to. the motor urea, of the rarer 
parii'to-mcipital and not the more freipient tempero parietal variety. 

{g) f imbs rini'l. convulsed, or twitthinj.'. it is only t«M» probable 
here that, in addition to middle menin}{<'al extravasation, contusion 
or laceration of the brain gubstance will be found »t more spots 

than one. . i . 

(.•») CoHiiitl'iii i>f ihr iiiipih. Whilst this may vary, there are at least 
three conditions which are important. 

((f) In an uncomplicated case of compre,s.sion from middle menin>;eal 
haiiuorrhage the pupil on the injured side, after an initial transitory 
contraction, becomes dilatetl and fixed, i.e. does 

»^ not react to light. The pupil of the opposite side. 
^ which at first is normal in size and reacts to light, 
also liecomcs ililiited and fixed in the later sta<;es. 
When present, this conditinn of the pupils is a 
valuable .sii_'n of the existence of compression, and 
also alYonU important information ;is tr) the side 
affected. Its value and explanation were first 
pointed out by Sir Jonathan Hutchinson.' 

(/<) If the pupils are natural as regards reaction 
to liirht, the coin|)i< ssion of the brain is ]>robably 
recoverable if trejiliiiiin;: lie immnliately performed. 
Further, it .s more likelv to he case of coni' 
pression ol the brain only without other inj'dy. 

{(■) If the pupils are' insensitive, often ai the 
same time dilated, the compression is probably 
extreme, and. while trephinin<i is uraentiv called 
]■„:. IJI. Tv,.i,n1co„ai.f<«--if likelv that in cases the brain 

tieiiof inipilMiiileft iiiid.llf will recover itselt after reiMoval )l the clot 
im-iiiiig<«l haeniDrrlMge. (4) flic piilsr. T\\\-i will varv accordinL' 

the case is one of well-marked. nn< omplicated 
extravasation, or complicated with contuMon or l8ct!ian<>M of the 
brain ; ami. if the concussion stage has been severe, according to the 
dcfiree to which the heart has recovered fnmi this. In well-marked 
UMconipliciited compression the pulse will lie slower than no.^nal. '■.(/. (iti. 
.")•_'. or even .slower. uTid usually full and labouriiii.'. If. later, a pulse 
which has been typically .slow becomes very rapid it n.eans tha' 
tlic final .stage of pjiralysis of the vaj;us lias set in and that a fatal 
termination is imminent. 

(.">) Coma. With regard to this the following points should ')e l)orne 
in mind : 

ill) The dejiri'c of will vary with the size ol tin 
branch injured, and the rapidity with wlii( ti the bhwid is rrtused. Whef 
the effusion is rajtid and the compression <.'na: the coma mav be a> 
deep ami complete as in aiiople.xy. But. in other i ases. it will l» lor d 
that though the coma is apparently dee^. this is not reallx m. : thus 
the patient may moan cvo^ntly w may move his limbs feebly when 

(6) The comnieiicinfr coma mav be taken for natural afc»p or 

' LutJl in HoKft liil U<i>,ii'. Is«i7, v I. ix. i». W 


druiikomit'**. in which fomlition th«' patifiit nmv l..- to lif until 

it is too late. 

(<•) In a few 08»e» the onwt of the coma is ilt fcrrfil tiM latf ; its 
onset is here sudden, its connte rapid, and it gem iaily nuls in death. 

((•>> R.-splmlio,, This, in well-Miarke«l caseH. is often »tertor«»u» un«j 
Honu ,vhat slow. In cases where stertor has not snperx-eneil to call 
attention to the existence of (•oin|>iv'';sioii. "tli. r iinil still L'raver altera- 
tions in the'atirm<; niav he present, altciations wliidi are warnnifs 
that the end is not far otT and that, in tli.' case .il niti iide.l tieplniim^. 
there is no time to hwe, viz. catchy, short respirations, cvaiiosi.-*. and 
jjuspinj;. irrepidar breathinp. ceasing f«»r inter\-als of ten or fifteen 
aecoiuls and then re|M'ated. 

(7) Slatr of Ihr sralii. Wlien the»>rv is (h'fieient. or when the 
.sifins of conipres,sion are not well marked ei elivinosis or contusion of 
the parietal and teiniKiraiv refiions. v'ivinj: rise to .i psi.pv or puffy fwl. 
are of great value. Tliis "condition will l>e . speciiillv in.iiked when tlie 
hemorrhage from the middh' nieninceal aiti-i v is linilini: its way tlironfjli 
some fissure into the tissues of the .scalp.' 

TrtataMBt Early trephining shouhl h«' |H»rfornied as foUows : J he 
scalp should be shavecl widely as mnch Inme may retpiire removal. 
Xo antesthetic shotdd he jjiven if the pati. iit is nn<onwious or the 
respiration failiiifi. If any he eniplovol the };reate.<? care must Im» 
taken on account of the risk of voinifiiif; aiul aspiration pnemnonia. The 
head being supported on sand hajrs or a linn pillow, the mi. Idle nienin>;eal 
area* on the side which is bruised, and on the side opposite to the hemi- 
plegia, is explored hv turning down a seniilum*. Hap. the centre of which 
18 one and a l alf iiiches behind the e.xtenial angular process ami one 
inch above tlie zvuoma roufjhly speakiii}.'. two fingers" breadth alwive the 
•"•gomi' iiid about the same '..eliin.i the .'Sternal an..'ul,ir pro.' (Fig. 122. 
p. 27'$). Kronlein distinguishes, aec.w.lin;: to the point of niptnre, 
three hspmatomata- an anterior, fronto temporal ; mi»hlle. temporo- 
parietal; and posterior, or parieto-occipital. He advises trephining 
first at the u.mal place; if no hasnwtoma be found here, a s4«coiul p«*r- 
foration fhould be made further back, a little above and lM»hind the ear, 
or. mor - accuiatelv. at the int. t .section of a line drawn backwards from 
the upper margin Of the orbit with a one .arried up dire<-tly 
behind the mastoid proce8.H. Eiilarg<'ment of either of these ojiemngs 

» ■' roiHaRoodKlM-oimonof ftiUiiithf.St. lloM<i' il M.i-. ii.n. Ii..'iir.-,l l.\ 
He' -1 hid .Swrr/irv. 4tli cl.. \>. 140 It tli. y.r:- ■ .1 I"....' " ' liil.l. m 1. 
Kiii -nr.- pr.i>«.'^ till' iiiiil.llr iii.'iiiiiu.-iil .iil. iy iiii; . ..iis,.l.-iiil'l.- .■ 
illM >kiill mid ^lill iiiiiii- .■xtrniallv. 

- L. H. Kttwlinu" (-'irfa. r maikiiii;>) >;iv.-s ♦li>' f.,tl,i'vi.. r iis.' -.f tlie Hiirfiii-.. 
anatomy of the mWdli meninKeal artory. " Tli. !iiHj<a.- iiu iiinti.rtl »ri.ry • ni. - ll" 
skull thnmjih th.' fi.rani. ii >.|>iiii>s.m., lui.I ilivi.l.'s iift. r u "IktI an.l i.irialile coin-, a' ni>> 
th. iiiiiMl.i f..s.MU into Iw.. main tv.iv.U-. 'I'll.' ^-at i.t LifMri al i..ii iiMially .-..i ii'-|«.ii.U I., a 
IHiint alMi\,' (lie ci'iitre .if 111.' /virmiia. Tli.' aiit. ii.n l.iaii. li w i'..| .iii- I'l.- lai j. r 

.if til.' tw.i. Iiiit It aN.i' t.i iiijiirv. sin. •■ it i- I'l.'li H 'l in tl"' l.'iii|>'iral r.'u' 

iiiilv liv a thill i.sM-oii.- liarri.T. Th.' ilaiiL-.'r / m ll. "ui f tin- may Ih> nmplitHl i«it 

livtakinn llir.-.' imiiit.-. (I) On.' l«'liiii.l tli.- .'M.'.ti il . #fciil,ii iireooHs of the fr-Mila 
iMine and one inch alwve tf* zyuema. (2) On.- .■.n.l a hulf inches Ih Iiiii.! .1.. -M'^rMa 
antsular iinK'!'-.!* and one and a half inch.'." almv.- tin- /yv'.ima. Iw.i iii.-l"- 

the, extrrnal Hiin'ilar iipm.^s -iinl tw.. iiiclw- al tin- /.VL'nnia. .\ ! 'i!>iti,-L.' tlii-c 

flm-i' |K)ii,t.-. iiuli.nli'-* th.'ivfnri'. tha- i.aii .if III.- ^!iil.-ii..r l.iaii. ii »lii. li i- hh-i Ii '''!'- t'l 

injiirv. 'I'll ■ aiili rii.r.livi- nf th.- v. ->. l Hill li.' . xiin-i il liy lr.-|ili'iiiiii: hmt any .M th. ><■ 

till.'.'' ii(.int>. hilt it i^ j.M'n. rallv |.i. f. ral.l.' In . h.".-.' th.' liiL'h.-st an in this way the'.-i..r'i .if the t:r<'iit wiiiL' .if th.' s|.h. ii.ii.l i" avii.l.'.l ; as an udditinnal ifa«Hi it 
sbnuld be addwl that, in the {xisition of (lointa 1 and 2. the artery frojuently runs in an 
oMmHWi ranal." 


will enable tin- Murj:.'..ti to tU'ul with a u.Kldlt' or |mriftiil l»iii|«»ral 
hmnatonw. Thf brisk ha-morriisp which tiikt-s pliin' from tlic whIji 
nMy be controlletl bv the xm of Speacer-W elk fcircep* and J.inu' .s 
t'mw fortvps. thp latter actinjt «» rrtractora alw» : Maklca'a cluiujw may 
also .'iiiiilovi (I for idmpr.'.s.Hinn the biisr ..I the Hap. The pericrttniuiu 
is thi ll carrfiiiiv si piiiHtci. miil aiiv lissurr or friuture Icwked for iti the 
bout'. Wlit'tlit-r one 1m' found m ^ 'i, a disc o| bone is iit'Xt rciiiovrd witli 
a full-sized tn pliiii"-. W lifii this has b. t'u exnost-d thf dot.' ha inorrliagf 
may still be p>in>r on, waniiufi of which will. jM-rhaps. be jjiveii by the 
pubatioii of the clot. This having been reniovwl by a small scooo. 
bv one of VolkmannV spnoiw. or better still by irrigation with sterile 
saline solution, the hii niorrlia>.'e may cease, or it inay continue profuaely, 
wellinjr up from a point <|uite out of reach. In such cases the 8nr|re<m 
mav. alter saviny his patient from the dainjers of compression, have to 
faci" those of most seritms ha'morrhaj;e. In such a i-onliufjc ncy much 
will depend on the accessibility of the bleedin^'-point. wh.-ther it is 
in the wall of the skull or in the foramen at the ; the following 
steps may Ih« made use of after the free exjnisure of the interior of the 
cranium itv »'ie removal of sufHcient b«me by Hoflfman's forceps (p. 312). 
A >;o<kI lij-ht is e.s.sential. an electric head lamp bein?! often of the fnvatest 

(I) Li'.Mture of the artery after removal of suflicient boiu- to expose 
the .site of injury. CJ) CrushinR tojj,.tli.'r with forceps th.' ed<;e of the 
bone fnmi which bleeding comes. (3) rnderriimiin>i the artery in the 
dura mater with a fine curve«l needle. (4) I' he use «if Horsley s wa.\. 
This is a mixture of beeswax 7 parts, almontl oil [ part, ami carbolic 
acid or salii vlic acid I part. Its use is especially indicated when the 
artery is ruptured in the bony canal, the wax U'tun forced into the 
oponui}; with a probe. (">) Another method of checkini: thi' bleeding' 
when the ves.sel is dama;.'ed in a bony canal is to plug this canal with 
a tiny Ixnled and aseptic wooden |>eg.- («) Forcipressure by means of 
a pair of Spencer-Wells forceps left in .^ilu for twelve hours. (7) The 
aiiove niean.-t failing, which is uidikely. ligature of the external or conunon 
carotid had better be resorte.l to.=» If such a step be really neetlful, 

a temporarv closure of th< hinmu carotiil (f/.r.) will jserhaps sndice. 

It is alw;.\-. to be remembered that hxal haniostasis is greatly to be 

' Pcrliiviw mnn- Inini- must be removed hy Kkull fon-f-iw datisfaotnrily to rJtpoim the 

Miir.', -I'll hv Ml ■('. Siiiiili. ami n»i-il -fiillv liv -Mr. W illi-tl am! 

Mr. H. .Mar li. .It .M. ll.iitli"ioin. » - llMspital in i a-.'^nf li.i iii'.nli«i;<- fmm the iliwemlili).' 
paUtiiii artci- ' /)/,. .SVic 7V.I/.. . \i. |i. 71. ,1111,1 

* l,il.Mtiirc iif liH'ciiiiinidii curiititl is jii,.titicil l>> i» Mii < i >ifiii i-:-. v I';'. l.uMvU I -imrr. 

Journ. Mxl. Sri., vol. ixxxi. p. .W), in whiih Mtomlarj- li^i iii. :rlia.f fmin the iiii<l<lle 
menintionl artfry. thrvv wwks nf t4>r a nhcll w.iimil in the feii ji.irii' >. jh^ii. was mi, ,1— fully 
amwtod by liKatim- of th.- ii.imn.m i imtiil. If t)ic .■..m!iti"ii llif ii.tiint 1" . iv 
crave. Iii.'atiir«' .>f the tninmi.ii .111. 1 imt tlir (.imtnl uill uimi ilh !.«• n — .ii. l 

1.. . a.s 1.. Mii; iniT.' niiirklv il'.n ■. .M..11 rir. rilly l>r. K. 1.. l(..liiii-oii. "f <;ii< riiMy (Uril. 

\: il. .Iiiiirti.. Di r. .11. l'.Hi4) r rt- ,1 -111 n—fiil raw with wvcriO |MiiMl- "f iiitiTi-st. The 

iMtit'iit, a woman I'll, lia I. 111 fallmi; fn.m a shop iDUiittT. ftriii k her hi-ail a>iftiiiiit a 
dbelf. Kbc had walked home and there vuiiiili-d IiI.kmI. Whili- ii llim: her htnry to a 
mediiul man. an hour later, »he Nuddenly twi ame iincunsc ii.ii.^ witli li ii lii'mi|>let.'ia. ami 
widely<Kl ritrht |m|iil. A fra«-tiirr was f.,iiml in llii' aiiLTinr fliinl . f iIh- li iii|i<iral 

1.1. «»a.' ninnim.' down to the bane. Tlir lion,. wlii>n Ir, |ililm-<1 wa.-i vrry ilnf I'li^h 
art, rial l.lood anil riot wi'lli'<l up into I Ir- . ■!« iiiiiL' as soon as this was made, ami as it was 

iMi|«is.ilile to ,se<' tlir Sonne of tin- IpI liiiL'. ilie riiilit i i.inmon l arcitiil waHthtl. Thi>« waa 

surcessful at iim-e. As the patient lame ronml from the ana-sthetir it waa Hcen that the 
hemiplegia had diMppeared. Have for rather tardy diaappeanUK-o of parafyaia of 
the tUrdnenre the lecovery «m anerentfuL 


prpfprml, nnil thtit. of the nM>th»i»l!» Rivi'n above. Huatiiri* »l the niiiMIe 

iiicninpMl iirt»'i\-'lf is tin- siifi-st. 

Dr. Sh.'pli. nl. i4 M«>ntiv,il rcconls ' an iustnu tivf casr of iniilillf 
iiu'iiinv't'iil li:i iiniirliii;.'i> in wliit li liLMtui"' i>f ili • <<>niiii<>n (iimiKl wim 
mic'Cfssfiillv rcsortrtl t<i. That tlu' li < monlia;;!' wa.s not m viti- at t-ist. 
uiiii pn'SHurc svin|»ti>in.s from tin* mIowIv s|>r<'a(lin;; < l<.t wctv imt U' likftl 
until the «ky uftor thf awuleiit. in fX|»luin<d iii l)r. Sln plit r.l'.s opii'i.m. 
by the fact that the nipture of the arlervwas low tlow n, w in rt- tlir dura 
inatcr wan i Iomi'Iv attachrtt to tlic hasc n f tlif nkiiH, ami where it netnleti 
cotittidcrublc ford to scjMiruti' it from tlif i>om'. 

A Urge hihI vpr>' tliii k i lot liuviiiK Ix-t ii cxixwil liy llir n iiicival of twii tn i'liim- 
I'niwns ill the lilir of i\ lisHiiinl frai tlin- in llir iililciior ji^iit of llir Irfl llir 
rin|>tv iiiciiiiiKral iirtri v coulil U,- hi-. h i.nnifv inn on llir ihini iiialrr. [■loml 

»aN frii'ly «i lliii« ii|i from In A l.iiv I'l" f '"'ik'. tlini' jm lii^ lont! !>> two 

ilii lii-i »i(lc. WiiH cliiKi'lli'il Mwa\ III 111- lio|H' «i( K.u liiiit; III. Iil. i.liiii; |ioiiit. Afti r 
a liiiv aiiioiiiil of clot h.iil Ini ii n iiios. il tln ir wat fiiiiou- M. i ilinw' fi'oiii liclort. 
Till- I'laiii mill dura mali r l« my lu lil a-i.|r la a liioail n liarlor il « « < ii tliat llw 
frarliirc ran tliioiiirli tlir foraiiicii ^|lilloMllll. aixl tln ii ai rms tlir ImhIv of till' -|ilii'noiil. 
Till' arli rv wan iillv lorn in llw foiaiiii-u. It wii» i|4fi«l«.<l lo tie thf WMnmoii 
nir«)ti«l wiiirh iiiiiiii <lliil. Iv .*to|i|i«<l th<- frt f lwiiiiH-rhaK>'- All tin- Wowl «'bt haviiiK 
bn-n waxhtHl nut. tlif iijiimm- at the baw td the Attii wan iiaclu-ii with imifrfafm (BBim-. 
The imtimt noon recovpivd i-onm-ioUHiii^H. Two tlayn fiitrr a» the fsnaw wan Iwing 
romovrd. thero w»» a tremfUilous spurt of KIimxI as tln' last pii ci' raim- away. Tlic 
wnnnd was thi-n>forf> again iKti ki il. 'riin r ilay> afin. llic paiinil liail .t rijioi. a 
ti'in|N-raturc of lo2-."i . ami |iai'alysis of tlii' li ft ^iilr ami motor a|ilmHia. Tht-m- 
ftrailually ilisa|i|N'aii'il anil iIh' waii/r was rcmoviii willioiit any iili'<.<linK ten «tay» 
afirr till' siTomI iiliiKv'iin!. Tlir |ialii iil iiiailc an l•^l•l■lll•n( hiom ly. 

Dr. .Shepherd considcrid that tin- paialvsis and ajihasia ««ii' ihie 
to the compreoBion ulTci-ti-d li\ the lai>;i' i|iiantity of lirniiy (lacki-d 
iodoform gatize. and not to li^ratuii- of tin- carotid, for thfsf .sifin.s tami- 
on only after the Hwond jiarkinji and were vciv tenijiorary in diiriition. 
The compression would liave been rendered Htiil greater wheji the gauze 
became soakeil with hhw(]. Dr. Shepherd resorted to ligature «»f the 
common carotid instead of |iliii;<.'iii,L' the foianicn. liccaiisi' tlii.s might 
have separated the frai tiiie in tlie liase of the skull. .\s in all ojierations 
on the head anil luain. where the jiatient's condition is a grave one. 
infusion of saline fluid .>«hould lie resorted :o when the aitery has been 

How far the surgeon should remain satisKetl with partial removal 
of the dot. or priH iM-d to remove the skull freely, and then the clot, 
more e.\tensivelv. niust ile|ienil partly on the conditions under which 
the operation is carried out. but chieliy on the state oi the patient, the 
size of the ck>t. and whether the depression in the dnia inaler l)e^;ins 
quickly to pulsa^rv and to rise up. If last points ate in doulit, 
tnere should be no hesitation, the loiidition (>f the imtient adniitting 
it. in removing more bone, and any clot which seems tiru« and dense, 
till all cause of depreswiiiii in the membrane is removed. 

Prognosis. With lef. i. n, to this imint. the followino lemaiks from 
a paper liv .Mr. .lacoli.son n, - (luv's Hospital |{e]iorts. vol. \iiii. may 5m' 
<lUot<'d : ■■ The chief |M>iiil> "n uliieli tlii> ilepemls an- wlietliei the middle 
meningeal extravasation is prohalily coinplicated with such ii iiiiies as 
extensive fractures and brain injury and, secondly, upin the date of 
trephining.', and whether, at this time, (he brain recovers itsi-lf ijuickly or 
not. With reganl to the former, or the existence of complications, the 
i Brit. Mfd. JouTit., IStW, vol i. p. 005. 


suitr.M,n will, if ask.Ml t.-stat. tl,.. pn.l.aM.. .vsult. hns.; '.i.s ..pinion J.n the 
histoiv of th.' cas.-. the s-'viitv .,1 tl,,' vI-.I-mmv. ,'.<,. li.Mjrlit ..ffalJ. whothtT 
at.v interval ..f In. i.litv lias l.f-n i.ivs.Mit an.l. il so. lor l,ow lon^' an.! lunv 
far has this beon well n.aikea. how far syn.i.tonis ol comim-ssion. 
well-defined henii|.l.'>!ia. the failini; puis.-, the stertorous l.nMtl.nif:. Ac 
are present or replaced by, or coniplicatetl with, those symptonis whieh 
are believed in point rather to lacratinn or contusion of the brain or 
its nieinhranes viz. restlessness, convulsive movements or twitchings. 
pulse -luick and sharp, or pvr.-.via. which show that infi..mmation of the 
brain has probablv sui)ervene(l wix.n the nijnrv to its substance. 

The seventy cases ujx.n which the above paper was has.Ml appeareil 
to fall into the three hillowinji jironjis : 

.\. The most hoitefid cases for trcphini»<i. \ lolcnce con.paiatively 
sli-'ht: laceration of the middle meningeal attery or its branches; 
fracture of skull, if jiresent. sli-.'ht and IocbH/ahI to one side. i.e. not 
implicating' the base : conipiession present, but little or no contusion 
or laceration of brain. Twentv-seven cases. 

B AcsN hoiu f'il ni.s,:x. Violence <;n>ater : laceration of middle 
meniiifieal or its branches: fracture implicating middle fossa; some 
iniurj- to brain, but this only trivia). Twenty cases. 

C. Ca.<ie.» prohahlif hnpelesx from the first. Violence very preat : lacera- 
tion of the middle n'leninjzeal or its branches ; fracture of skull extensive ; 
perhaps implicatin'r several bones and sutures both m the vault ami 
base : iniurv to brain verv severe. Twenty-three cases. 

Sub-dutal hsemorrhage. This obscure and dillicult subject has hart 
much lifjht thrown upon it bv a paper l.v ."Mr. \V. 11. Howen.' I he 
differential diagnosis of extradural Invmorrhafio. nitracramal suppura- 
tion, nripmia. idiopathic ei.ilei)sy, cerebral Invmonhape. and meinn<:eal 
ha'niorrhafe is carefullv considered. Mr. Bowen i.s mchned to rely 
upon (1) t"he lonj: duration of lucid intervals. CJ) The presence ot a 
.scalp wound, or brni.-*e. recent or remote. Ci) The i)rcsence of Hutchin- 
son's pupil (.sec p. 2<ll). which is however rarely j.iesent. The only 
treatment is earlv tiephinin>;. Tiie foUowinji ponits ot i)ractical imi.ort- 
ance are brought out by Mr. Bowen in his paper : [o) No iracture may 
bo present in these cases of sub-dural ha inorrha-;e. Operators \\hi> 
mav be inclined on e.xploring a case to close the wouml because the 
bones are foun.l uninjured, should bear this in mind. (6) If. on opemnfi 
the dura at more than one place, no clot is found and the brain bulges 
thnniv'h. pulsatinj:, the following.' po.s.sibilities must b<' borne m mmrt : 
(I) The <liaf.'nosis mav be wron^t and a -erebral abscess be present. 
If this is excluded, and if the passage of a curved director mto th." 
arachnoid cavitv for the purpose of exploring neighbourn,^- areas i)roves 
negative, the oi'.ijosite side of the skull slnmld be trephined and a carelul 
search mad.' tlu'ie. (J) .\s in the of ini(hlle meningeal hannorrhagc 
it mav be a case of contre-coiip. (:!) Where sub-dural ha-iiiorrhage 
is present, tenseness and non-pulsation of the dura mater are far more 
valuable than the colour of this nwinbiane. - If colour he relied iii)on. 
two conditions at least may lead to error, one beiim that the compressing 
agent is not alwavs blood, but may be blood and serum, or serum aione 
when there will be no discoloration, notwithstanding the presence ot 
prniiouiK T(l ; the other that a thin layer of blootl over 
the surface of the brain, assoiiated with si vere (ontusion. yet incapable 
» Gtiy't Uo^i> l 'I lit i> irli, vol. li>c. 


of compres»ion, nmy «ius.- .lis.ulun.tion. aiul this nn.y i.lso ■.i\>\»-.n- U> 
ho present when causv.l l.v tl,.- vny .listondeil v.Mns ,.n tin- mh ..I 
th.. l.raii, i..rs8.Ml ajjaiust the mi'inbrane. (4) Wit . lopii.l to tlu 
r.M.H.val ..I tl.o clot there is ..othiiiK to be aadeti to the actount given 
at ,) 'tit;. (.-.) lla n.oiiliaj:.' nmv be dittieult to stop and may rei-ur 
,,.uslv. I., sml. eases it is possible that a sinns has been oiHM.ed 
l.v a fnuiun- .unni.ii.' into ti.. l.ase. Cerebral vessels n.av require 
liirature. ((i) As t.. the advisability of (Irainaj^e no rule ear. be laid 
down. Onlv wh.-n it is eertain that all elot has Im-.m, ivn.ove.l an< that 
the field ..f" oi)eration is sterile, should the wound be ^i^UrvW e ose.l 
Th.- foll.,svin^' ease, under the eare of the late Mr. H. >l . AUinKham.' 
is a most interest one. the bleeding' having apiwrently eonie from a 
laceration of the frontal lobe. The h n-th of the " latent interval 
will be noted. 

V ,na,.. . t. 4e. w.s ;„l,„itl.d t- th. Northern Ha-l-ital. having f""«» "« 
a t ranua, whil,. half .h ank. H.- .•..■nplain.'.l -/ pah, in th.- l.-ft .h..ul<l.-r ; tl..;n- ««« no„.... of injury to the hettd. Th.- .U'Xt four ,la.vs ih. l-atu nt > ' 

a,ulirrital,lewhen.liHturlH-.l. Then- was no l-aralvsis -^y -' ^ ' ' 
mzed with couvukions. Tlus,- h- nan m, thr l. tt M-h; -i th.. fa,. . ' ' 
drawn up. ami tho m..u...1 ir. rUuc s|.a.m. ;.• mas,- of th.- . . k « - 
mxt air.. •t..<l. a.ul sah«-.l....utlv tlu- 1. ft ai.n an.l l.-. 1 h.- Im a lan^ «a> st..,lo.ou^. 
a K 11.1. »as tur,u..l'.U.wn in .h,- ri,h. | r. ,ion an.l ^V''-. ' 
„.nu,rnl ..[.r (!»■ right lis.sMr.. ..f Holan.lo ah.,ut .wo an.l Imlf ' "M^^ 

at»l and a half in. h.s ahov.' th. .M. inal an«K- of ho 

bra.u h of tl... nn,l,ll.. n..-.nnfJ.Ml ran a, ro>. th.. . xp.... .! ' "■••^"'^'1^:: J^^ ZZ 
bran.. .11.1 n..t palsal.'. an.l sIm.w.mI a hla. k M.a>s l,. n.alh It ; th.- art.TN Ihii.R 
.: ' .nv.!' th.. .hn'a nul- r was na is...! an.l a lar«.. .1... ...vpos-d, Ab«u h"- -'-"'-^^ 

of this having. iH . n r,. v .l . hi- tly t.y irr,«atHm. a large V'V'*>77*1^;^ y,;^ '^^^ 

U.S th.. lingor 0O..1.1 r..a. h ; tl... brain ai.i...ari.d to be much hicerat.-d over the frontal 
lobe. The patient made a good ri-covery. 


Indicatioos lot exploring ; symptoms and diagnosis o! traumatic 
cerebral ataeen. Manv of th.-s.- are -iv.-n at .somewhat fulh-r U'li-th .n 
ref.-ivi.c.- to that form' of cerebral abscess which, as on.- of the resu ts 
of otitis me,lia. is,.d at p. Xy2. To begin with tl,..r.- is often the 
hisf.rv of an inji.rv.^ This n.av hav.- lavn a stab with a knife, a graze 
of the head with brief c..ncussi.,n. a fractur... .■spt-cudly a compound 

one, a blow with a stone or a -lancin- bullet. () ly an abscess 
may follow a trifling superficial septic injury, such as th.- inte oi an 
insect, the infection reaching the brain thr<.ugh s..n..- of th.- .niissary 
veins. Again the nasal fossa; must not be forgotten as shown by the 
case mentioned at p. 4(51. Dr. Carson^- mentions the cas,- of a child 
where the infection. startiuL' iit a nasal catarrh the result of an injury, 
...xtended thr..ugli the cribrif...... i.laf t.. tl..- brain and led to an abscess 

which terminat.".! fatallv. Oft.-n. bet not always. a latent 
period devoid of brain symptoms, whic.i may last fmni a l.-w . .;/. loui 
davs to thr.'e or four" weeks or much longer. I hw lat.-nt p.-n-.l is 
siiccee.l.'.l by brain symptoms increasing in severity and gomg on to 

^ hi.r a ]:^;.l^if.nn.y U not always l--t and^hU i-Jjn 

ind.c...t.on for alw.iys .•va„>,j. I... ..ay woand or scar, ami .-xplonng .t, h«»evir un- 
imtKirtant it may nevrn to U-, in thest- ibm-h. 

« Xtw i uf*J/crf.Jo«r«., April 27, 1«05. 



thoso of (omim'ssion. viz. licailiichc felt over the side injured, hut not 
necessarily most intense at the injured spot; nausea or vomiting; 
some pyrexia, altliouj;ii tlie teniprature usually rises slowly, if it rises 
above the normal at all.' Optic neuritis may he present. 

Other symptoms are mental dulness (the answers long delayed, but 
intelligent "when they come), a slow pulse, perhaps rigors, progressive 
emaciation, perhaps accompanied hy vomiting. Whether local nerve 
svinptoms <.;/. disturbances of sen.sation and motion- are present 
nuLst depend On the position oi the ah.scess. If the injury has heen 
over the motor area (Figs. 1-J2 and nerve sym])toms may he clearly 
marked, but if over the anterior part of the frontal or teniporo-sphenoidal - 
lobes, they may be entirely absent. Thus hemiplegia, a paralysis limited 
—«.(/. of upper limb and. later on, gradually increasing— epileptic 
seizures, spasms, spastic rigidity, all have been met with, but must 
1)V no means i)e relied upon : and even when paralysis is present it may 
escape observation, as when there is slight paralysis of the nui.scles of 
the lower half of the left side of the face, and some loss of power in the 
left hand and arm. but only te nporary.^ Here, as in otitis media, 
there is but one rule, and that is. that in all cases where an abscess of 
the brain may be present, exploration should be undertaken, and that 
this step should not be deferred. 

For the surgeon, who is watching 'lat he believes to he a cerebral 
abscess, nuist always remember that a er a period of latency, which 
may last weeks oi' more, acute symptoms may set in suddenly and 
quickly close in death. 

Operation of trephining for traumatic cerebral abscess. As the 
fatality of cerebral abscess, if left to itself, is so high— 9(J to 100 per 
cent.- trephining is abundantly justified. The chief difficulty is, of 
course, hitting off the seat of thl' altscess. especially in cases where there 
are no definite nerve symptoms to guide and where the history of the 
part of the head injured is indefinite also. 

To obviate the necessity of multiple tn>phining. Dr. Fengor and 1 Lee. of 
t'hicago, have reeommendt d.* us easier and siifc r. exploratory puncture iiiiil aspira- 

• On this and otIiiT imints irfiTonco may b- made to p. 'Mi'i, Prof. Nancrede (/of. 
iiiprit cil., p. !••">) wrili 1 thus : •• 1 bcliove that an abscess mvolvitig the cerebral tissue 
alone will !»• ae( iiini)aiii(Ml, in most t iiM's. by a subnormal or, at least, a normal tempera- 
ture. \Vh(r(.ahi(;h temperature is noted. eitherthe ]ius eolleetion isa loealised s\ip))ura- 
tive arachnitis Hmited l)V adhesions, m then- is a iiietiiiiLritis in a(hlition to tile abseess." 

- With re<;ar.l to the' lar^'e idlect i. iii of pus found lieic. Dr. Veo (/or. ■■<((j,ni cil.. p. 8S.")) 
quotes as follows from Huyuenin [Xii, ni-ufi iis I 'i/cli>ii<di(i. vol. .\ii) : •'The ditticulty of 
diagnosis is increased bv the eireumstanee that no bands of fibres, which are direct 
eondiietors of sensibility" or motion," pass through this lobe ; and, therefore an abscess 
here ■ may attain a considerable size, and may cause general symptoms of compression, 
iM'fi ire any distinct symptoms of local disease arouse the suspicion of a localised affection 
of the brain." 

■' The value of a( i urately noting symptoms whic h, thou-ih of but brief iluration. may 
1m' verv important jjuides in treatment, is well shown by a of Sir. \V. .Macewen's 
{Litiir,). ISSl. vol. ii. p. r,Ki). 

A boy. aL'ed 1 1. ,»as admitted into the Clasiiow Royal Infirmary, two weeks after a fall 
u|ion his head, with a partiallv healed wound and bare bone over the left eyebrow. A 
week later he had a ri-' .r. I'ivi- days later, or twenty-six days after the injury, the patient 

hail a I onvulsion i .md to the ri^iht side ; when this had passi'd otT. he was distinctly 

aphakic. The scat of I lie abscess now sccnud to Im' the thini left frontal convolution, 
and trepliiniu}; was iiroposed. The friends, however, refused to permit this, as the 
patient had r-covered conseiousness. though they were warned that the improvement 
would only Ihi temporary. Thirty hours later, the convulsions of the right side recurre?!, 
the temperature rose quickly fnui'i 101 to 104 . and the {tatient died before the operation 
could be iN'rformed. The situation of the abscess was veritted after death. 

• Tra»». .4 we'. 'Surg. Ahuoc., vol. ii, p. 7S. 


tion. This must !«■ tloiic mclliiMlically. willi :i iii'cilli>. four im lii s Imiir, m I m an 
(•x|iloriii« syiinnc 'I'lic nndli' sliuulii not lie t!ii) line, and tin- ii:\iHi<- .-ImiuIiI br 
powi iful i niint^h tii make sutlii icnt snctiim. as a line iitcdlr is ii adily pliinurd with 
liraiii siilwtan. c. 'Phis niav 1m' easily taken for pus. The nwdlf. 8t<'rilifc-<l. w 
pushed through a trephine -hole, straight in, in iv <lctinite diriH-tioii. for half an inch 
or one ineh ; the piston '\» then withdrawn a little and, if no pus foIlowM. the nt^dlo 
is pushed hnlf on inch further and the piston again withdrawn. The <k'pth to 
which it will be permiiwible finally to push the needle will, of course, vary witli 
the position of the trephine-o|)eninB and the direction of the ptmeture, th«- singron 
Ix ing (Iiiided l>v the anatomy of tlie hrain. The punctincs are to Ik- rei« aled at 
intervals of half an inrli or one ineh. the utmost rare heing taken to push the needle 
in straight and to avoid all lateral movements. The loss of resistance and the 
sensation that the jMiint moves in a lavity are to he earefuily wat< hed for. If. 
iifter a reasonahh' numlsr of punetures. no pus is withdrawn, the operator may 
(eel eoiiviiu i d thaj none is pre>ent. .\n alisi-ess in the lirain is usually UH large a* 
a walnut, often nnieh larger. More details are given at p. 357. 

I'nneturing liealthy brain tifwue with a tine, perfectly aseptic needle can do but 
little mischief. 

The needle should In- kept as a guide till the ab«eeHH-cavity in definitely oin-ned 
either l>y inserting a pair of Lister's sintis-foreeps or a sharp straight bistoury. The 
abscess nnist he thorouglily drained anil made to close from the liottoni. 

A drainage tube should be used and should be kept in position by 
stitch securing it to the margin of the skin. 

Tlio following cases of tnttiniatic cerebral abscess, in addition to 
those given at p. I'til and in the footnotes to p. 270. are good instances 
of the disease and also of its successful treatment : 

A hiltourcr, aged OiO. was admitted into the Middlesex Hospital, under the care of 
th<' late .Mr. .1. \V. Hulke. a fortnight after being struck a glancing hlow on the right 
temple by a falling hulder. w hich st\iiuied him for a few minutes and caused consider- 
able bruise. He continued, nevertheless, to work as usual until the middle of the 
third day. when headache, whieli he ha<l from the time of the accident, became very 
severe -so severe that liis wife feared that he would go out of his mind. On admission 
the i)ulsi> was .">(>. and the temi>erature slightly below ' he normal. The patient s mind 
i was unclouded. About one week later, in the night, he became inseiisible. and in 

the morning the right upper and lower limlw were found absolutely palsied as regards 
motion, and nearly so as regards sensation. When the arm or thigh was sovercly 

Emchcd, he gave scarce any sign of consciousnefw of it, but shrank slightly when the 
It limbs were pinched similarly. Two days later. siMtstic rigidity of the left arm 
supervened. A small disc of tone cut out beneath the bruised bone on the right 
t«mplc apiWiired uninjured. The dura mater bulged up so tensely that pulsation 
could neither be seen nor felt ; its ex|)osed surfa<'e ap|K'ared healthy. A lu-edle 
eonneeted with an exhausting syringe was [Hished through it to a depth of one and a 
quarter inches. A brownish tnrbitl fluid rose up into the receiver, and continued 
to flow after the needle was withdrawn. The minute o[M'ning was enhirged with il 
scaliK'l. and a considerable (plant ity of fluid esca|M'd. The tiaps. which had been 
retlected. were replaced. Next morning the spastic rigidity of the left arm had 
gone. On the second day slight retmii of iK)Wcr was noticed in the right limbs, 
and bi'fore t he end of a w.vk t heir palsy had disapiK-ared. For a very few di.y.-i after 
the oix'iation the dressing was wettcd and (li.scoloure<l by the fluid which continued 
to ooze, but the woiuid h^oii hcaleil. and two months after the oix>ration the patient 
apix<ared quite well. 

It is interesting to note in the 'oliowing cose that Mie hemiplegia 
which followed the operation was only transitory. It also shows that 
grave sytnptonis may be latent for as long as live months if r skull 
wound remains unhealed. 

A thild, aged i\. had sustained a severe compound fract\ire of thi^ rig., frontal 
bone. The removal of some portions of necrosed bone led subsequently to a slight 
hernia eereliri. The sinus persisted, lull the child seemed well in other rcs]K< ts 
iMitil alunit five months nftcr the aei idcnt. whesi left-.slded eonvulsioiLS (chiefly of 
the inusclis of the face and arm) lanu' on. i.nd an alarming condition rapidly 
di vi loped. The sinus was oiH iied up and a director jiossed for a distance of one inch 



i„to tl... right frontal lolx- downward, and backwawU. A fr.-.; How of fHiil imih 
.Kcurrid. ..n.l aft.-r tk- cavity had bron wa«h.Kl out wrth ot.on (I iii40) a 
dMinagc-t..lH. was imK-rt.ML The latt. r wan n nioved at the end of a/ortmght. 
Ltft luniipUBia followed the operati.-.i. but it i«iMed oil -onic twenty-four houw 
sabaequently. Recovery was rapid and complete. 



This is one of the advances in cranial sur<,'ci v. tlic results of which 
I,av(> not come up to tlu xpectations formed of it. The operation— 
,„H" ot the most m the history of surgery— after being almost 
abandoned for centuries, has been again taken up in recent years, with 
all the advantages of modern surgery, especially in those cases where, 
after an injury, epileptiform convulsions begiiming m the leg. arm, or 
face are due to lesions of the corresponding i)art8 of the motor area. 
This form of convulsion forms a large part of the epilepsy which beara 
l)r Hu"hlin"s Jaekson"s name. It is to be feared that any candici 
inouirer" w. igliin-' fairiv, unsuccessful as well as successful cases, and 
attacliin'.' due importanee to tlie facts that many of the latter have been 
published prematurely as to Hnal result /.('. before they have been sub- 
mitted to the time test --will come to the conclusion that the result of 
trephining for traumatic epilepy is a disappomtmg one. it wmII be wmtli 
while to go a little into detail with regard to the grounds which lead to 
these coiu lusions : j , i. i. • x 

Results of operation. Later collections of cases and (what is ot 
paramount importance) keeping cases more carefully uii.ler after- 
observation, have shown that the operation for traumatic epilepsy has 
not come up to the expectations formed of it.' One of the most exten- 
sive of cases with careful analysis of results is by (Jraf.'* 

Graf has collect, .! 14(i s. Of tluse 71 were trephined, and though the dwa 
was i.Kised ill xomc of tlus.v th- l.rain was not incised. I" /e™*™'* *"* 
oit^ratlve ,'ro.v.! was cxteuded to th.- cortex cetehri. In 56 of the latter group 
there wax removal of spicules or fragments of bone, or incision or excision of a cyst 
or ii inoval of a cicatrix, while in the remaininp 19 the cortical centre was - x <;'«■'' • 
Of the total number there was an oixratioti mortality <if <)1 \k-t cent, riity- 
hn-e of the cases were under observation for too short a inriod to estimate the 
result of the operation. Of the n.main,l..r. Sr,. or per cent, were fr.^- from reru,-- 
rence at the end of six months. 2:2. or l.Vl per vent, were improved, while .(I., or 
27-6 per cent, were failures. Oraf found tliat successful cases without recurrence 
at theend of three years were at tl» most only 6-5 per cent. 

This want of success can be readily understood from a consideration 
of the possible pathological conditions (.sec p. 274). It is of course 
ciuite possible to remove spicules or depressed portions of bone, or to 
remove any cyst or mass of connective tissue. As the result of the 

» Aencw ( Tra.i.t. Amrr. Surg. .U«,e.. IS'.ll ) «ivf s results in 57 cases operated ui>on at 
Philadelphia. Of these 4 died, 4 were cured, 4 were operated upon too recently to v,M.turtj 
an ouini on, 4 passed out of observation, .12 experiene. d temporary l>cneht. and !» obtained 
no relic Of those reiH.rted as cured 2 had been under observatmn for only 1») months- 
to. short a period to l,e sure of a permanent eure. Dr. K. ( i. Mas,,,,. „f New \ ork 
tobulat " ( W, </. „■... vol. i. lH!t(i. p! :U:t) 7(1 cases in a pai,ur which is especially valuable 
b^ause he r ef,.s,.s to aeeept a„v eas..s as •• cures " unless the ,«iticnt8 Save been under 
^r^ation for three yeari and have ha.l no return of fits. Starting th« ^»«^ 
proviso he linds 8 cases, or B-3 per cent, can be accepted as cures; 6 (or 4-2 percent.) 
ihowod iraprovcmrtit of more than a year's duration , in 14 (20 per cent.) there was no 
imnrovemenl ; in three cases death was due to the operation. 

im^yemem .^^^^ ^^^ .^ ^ ^^^^ Oppenheim. Textbook o/ Nervotu Dtttuut. 
p. 1229. 


operatiuii. however, sdine sriiirinji or adhesion is ct'itMiii to take jtlarc 
which t«K) frei|iiently keeps up the (•erel)ral iiritation. Still more is it 
uaeloss to break iIuwm udhesions between tlie (liiru uiitl pia or iM'twtvn 
the pia and brain, because they will inevitably re- form after the o|M'ra- 
tioii. Kveii excision of a ])orlion of the cortex is certain to lie fohowed 
by a cicatrix, wliicli. in turn, will act as an iriitaiit. It is nsnally Ini- 
possible to (leterniine the exact pat holoiiical coii(lition jiresent lielore 
hand, and it be remembered that in some cases an injury to the 
heail may cause contusion of the brain and Hubseipient sclerotic chaiifres 
in the cortex without any fracture or depression of tlie iione. In some 

j-ic. I-'-'. 

of these cases, even when tlie initial lesion or |)orti»)ns ol the cortex are 
retnoved. the slowly established habit, created by years of e.\< itation, 
will remain.' 

The treatment of traumatic epili' shoidd. to a certain extent, be 
preventive. .Ml flepressed fractures, however small, should be elevated, 
for though no .symptom.^ may \h\ present at the. time, such injuries are 
aj)t at a later date to produce epileptic convidsions. 

The surgical treatment of epilepsy is thus summed up by Professor 
Oppenheim : * ( 1 ) The operative treatment of non-traumatic true 
epilepsy is not justifiable. (2) 'I'lu' operative treatment of Jack.'<oiiian of non-traumatic ori<;in is admissible under certain conditions, 
c.(j. if an operable c()rtical affection (, tumour, or abscess) is jjrobably 

' Sir t\w rcmiirks of I'mt. Niincrcilc (Ann. of .S'lir;/.. Isiiil. vol. ii. p. 122). Also 
.Siiclis mill ( icrstiT (.1 III' r. Joiirii. Mi li. Sci., I >i't. I s!Mi|. Kin- an rx|irc.-^iiiii nf t lir <i|>iiii>jii 
»'i (it-iiiitiii hUi>iuunb .^t* tilt! piiK-fi'ituiui uf llio Gt'iuiiiu tSui'gK-ul Cuiimo.-* (.lull, uj Siirtj^, 
December 1903). 

* Tex&ook ofNervout Diteaies, p. 122i). 



DD'sont. ShouM this net be so the proipects of a soccewful operation 
are slicht. Operation is indicated in cases of cortical epilepsy 
following injury, especially if the ci.atrix practieally eorres, t.. a 
motor area. If at a distance from the Kolan.hc area the ixjint for 
trenhininc should be that indicated by the attack. (1) In all cases 
scars, .spicules of bone, &c., should be removed. In many cases it is 
advisable also to excise the cortical centre. 

But wliil." it is authoritatively provetl that the value of trephining 
for traumatic enilensv has been greatly exasperated, owmg to many 
operations having been ill-a.lvised. and als<. what is less «^y ''«»J> «• 
to premature reportinR of successes," it by no means iollows that this 
operation is to be aban<h>ned. It is to be employed on careful and 
s. .entific lines. We should be more careful in promising success save 
in cases of recent date, where there has not been time for the changes 
to occur which, as we have seen, must render recurrence of the con- 
vulsions after a time a matter almost of certainty. In other cases it 
will be onlv honest not to hold out much liope of cure, but to explain 
to the patient and his friends that th.> operation or l.-ss must he 
uncertain; that its dangers are slight in experienced hands; that 
while cure in the truthful sense of the word i;; unlikely, som.^ relief will 
almost certainly be granted in the number and severity ot the tits ; 
that as to anv headache. &c.. from which the patient suffers, it is 
impossible to state what the amount of relief will be till the parts have 
been explored : a. id. having .^ai.l this, we .shall be wise if we leave the 
decision in the hands of the patient or his friends. 

For as we know nothing of the actual causation of epilepsy m these 
cases, so we must rest uncertain as to the relief which a trephine-oi)ening 
on wide lines mav give. If headache or optic neuritis is present, these 
will be relieved. As to convulsions, we may hope that, m cases which 
an' not of too long standing, the relief to tension may help towards 
recovery the impaired vitality f.f cells so delicately constituted as those 
of the brain. In other cases the opening may allow of the intracranial 
circulation undergoing fluctuations, to which it is inevitably exposed 
without the unstable cortical centres becoming congested and irritated 
and prone to explosions, as would otherwise be the case. 

Condition of the parts which may be met with during the operation 
and which may have originaUy caused the epUepsy. (1) The scalp. 
Shaviii" often reveals scars known or undiscovered. A\ hen.operation 
was again resorted to in this disease, sonu- years ago. it was hoped that 
tenderness of such scars would be a valuable guide and <liaracteristic 
of cases to be benefited by operation, 'rims Mr. Walsham' fouiul that 
of eightv-two cases, the scar or spot was sen.sitive, tender, or pandul 
in fortv-two. Pressure in .some caused vertigo, convulsions, rigidity, 
or spasmodic twitthings of certain groups of muscles.* Larger col- 
lections of cases have shown that these instances are fewer than was 
hoped, the share taken in epilepsy by tender scalp scais »eing a small 
one. In e'ght out of the forty-two cases collected by Mr. Wateham 
a sinus was present leading down to bare bone. 

{•2) The j^Tiosteum. This may be found extremely thickened and 
very closelv adherent to the bone. Excess of vascularity may also be 
met with. " O.stcophytic d(•po^sits have not been observed. 

I St. Biirlholoww-^ Hospil,!! Rfporls.\n»S,vol.xix,Tp.l21. , „i.™ 

» It ia especially in those cases in which pressure on a tender scar produces convuL«ive 
movemenU on the lame nda, that the surgewi may be contwit with removing the scar. 



(3) The akuU. Lesions of all kiiuU have hevn pn-Hoiit. DcpntwionH, 
fractures, fissures, are common. From the inner tabh- a spicuh* » may 
project iiiwardi. With regard to th«ne last conditions it is very note- 
worthy that in one of the cases collfcted by Mr. Walsham, though 
nothing was dctcctiMl at tin' opiMation. a spicule was found, at the 
necropsy, not far from the trephiiu'-liolf. 

Another iMiint which is of great ini|)ortai,.i' witli rc^'anl to the 
indications for trephining as given by the state of tlie skull is this. 
Several cases have been recorded which prove that it is not always safe 
in trcphininj? for to rely on the position of a fracture, unless 
that fracture foincides very closely with the s|)ot selected for trephining 
from the character of the tit. Thus, in two cases r.-Iatcil hy Dr. Starr. 
(I(' fractures existed, epileptic attacks liad dcvc|i)|>cd siilisc- 
quciitlv to them, but the fit. vliicli in i)oth pafinits l)ci.'aii in the arm. 
indicated disease in the middle third of the motor area, while the position 
of the fracture was upwards of two inches away from this spot.- In 
another case where the surgical indication or p<^ition of the fracture 
was put aside in favour of the medical one. or the evidence given by 
the fits, the latter proved to be the correct one. as on raising the liutton 
of hone a splinter from the internal table was found penetrating the 
dura mater and brain, though at the spot selected there was no evidence 
of fracture. 

(4) The membranes. Before opening the iuend)ranes the surge«m 
should remember that it is at this stage that danger begins. Aseptic 
trephining in experienced hands entails no risk, hut it is another matter 
when the membranes are o|)ened antl the brain itself is interfered with. 
The risks of hicniorrhage. sudden civssation of i)reatliini.;. shoik. infec- 
tion, hernia cerebri, have now to be faced. Both the dura and pia mater 
may be found much thickened, blended with each other, and adherent 
to the cortex. In some cases they form respectively the outer and inner 
wall of a cyst. 

(')) The brain. When pathological changes are present in the part 
explored, the corte.x may be found compre.s.sed or indented, stained, 
sclerosed or softened, (iysts in the corte.x. perhaps the result of old 
ha'morrhagc. are not uncommon lesions, and are amongst the most 
hopeful for treatment. If removal of the cvst is impracticable incision 
and drainage should be employed. Any blond clot must be removed 
by curetting or carefully cut away. If old, it may resemble yellowish 
scar tissue. If the dura has been opened to get at it. the edges of this 

1 Tho term pxostnsis is somctimos aiipliid to tlif dcpn ssi d tiiine ; tliis. when circiim- 
Rcribed, is easily <lealt with. An .illiccl cDiiditioii rarer, and one murli iiiiiro dillieult tu 
deal with, is desi ribed by Dr. Kiheverria {Arch. tien. de Med., 1878, t. ii, p. A 
conical. irreKular projection of bone, ineasiiring 2 x 2.} inches, hero compressed the dnrfi 
mater and brain, being situated very close to the superior !> imitudinal sinus, just to the 
left of the occipital protuberance. In trephiiiiriL', thc^ cro rnlen-d into tliis .•xo-to>is, 
the removal of it, provinjr most laliorioiis. tlie operation I lini; three and a half hours. 
The patient recovered. A case of Kochler's. of Hcrliii (limlxrhi Mul. llirf/i., No. 40. 
'88!t), illustrates a less loi aliscd condition. A swonl-cut had injuriMl the bone, without 
i.pression. Kpileptic fits foll. weil in six weeks. About a year later trephininsr was 
successfully performed. Tho dura mater was adherent, tho bono much thickened and 
covered with thorn-like processes pres»in(r on. but not ix'.^oratitiB. the dura. Ifc<foro 
deciding whether any diffuse thickening of tho bone is really morbid tho varying' t liickiu ss 
of tho skull in ditToront parts must be remembered. Uood illustrations of a blunt spicule 
from tho internal table arc given by Dr. WiUiamion and Mr. Jones {Brit. Med. Joum., 
vol. ii. INUit, p. itlU). 

" Such eases cmjihasise tho need of sweepinK a probe around the margins of the 
trephine- hole, so as to explore tho neighbourhood thoroughly. 


iiioml.raiic mttat be drawn together with suture**, drainage being employed 

if iH'i'dflll. • II f II » 

Hffoif cutting' lliioii^'li tliickoii.'d iii.Miilmiiif.s. csin'ciiilly il luUioivnt 
to the bruiii. the siirp-oii should ifiiH-mluT tlic fi>llo\vin){ cuso. whiih 
oeciirred In the experienced hands of Dr. Oerrter bimaelf : 

Til.' piiliciil. ;> I. IT, Im<I iH'fn al. ' ■•ii twu r Mori: Tlir . i.HV roiitinuiiiR 
aixl 111.' piiliriil hrmn i.iixioiis for a Wu-. ..|K rali..n. aii all. nipt was ina.lf to U-xm-n 
Ih.' t. iiNioii . aus.-.! I.v a M-ar at llir of tlir lirst oiM-rat ov.T the Wt »rm. 

.•.litre CultiiiL' tliiV.iiiili this tli.' »iir« i f.nmd an t-normouHly thlckfiM-rt 

,„..„,|,ra,..' I., tw. . II til.- .lurii iiiul t\w 8cal|i. In tlu- ntWmpti. to «-|»mt.- 
ami . 111 ilinuigli tliiik.iu.l iiifinbrano. cxuvwivp hwiwMTiwgc occurrf<l, wIih'Ii n 
was imp.)ssihl<- to «hi>ck for Homc tiim-. The juitient did not recover from the shock 
of tlu' <«|»rution, and diwl in cotlajiw thrw dayH later. 

If nothing be found wlu-ii tlu- duiii is ..p.-iu'd. the sui>'.'<.ii may. 
h. f..if drciding to interfere with the brain itself, explore the neigiiliour- 
h...).l of the wound within the dura with a blunt-pointed instrument, 

('.;/. a ( iii vf.l. il.'xil)!.'. stt.rilizf.l diioctor. By this means a clot or cyr*, 
which woid.l ..tli.Mwisi liav.' lucii missed, may l)e detected, and d- 
with bv enlurjriii^' til.' op.'iiin}.'. . 

But even wli.'ii clots and cyst.s may .seem t.i have Ix't'ii satis. actonly 
dealt with, ami the fits cease at once, mischief in tli.' brain may co-e.\ist 
(especially if the case be one of long standing) and lead to their recurrence 

'* "ri't'Mn'^j.irity of lesions of the brain will however be found to be much 
less am.-nal.le to treatm.'nt. How varied they are is shown by the 
followinn list ennm.'rated liy Dr. Starr : ' " .\iiv atT.'cti.m of the menmtr.'S. 
whether pachymenin^'itis or l.'i)tomeniitj:itis. »i tratimatic .ir syjiliilitic 
or tubercular oripn ; or new jirowtlis n])on or in the cort.-x of tli." hrain ; 
or cj-sts formed as the result of small circumscribed hu-morrhages. or 
of .siMrts of itening fmm embolism or thromb«)8i8 of a cerebral artery ; 
or circum.s. il)e.l encplialitis or sclerotic patches, may act as centres 
of irritation in tli.' corte.x of the brain. The majority of these forms 
of disease, when exactiv localise.l in a small area, appear to be tniceable 
to traumatism, either to a iil.iw. a fall on the li.'ad. or to a fracture with 
or without il.'pres.sion." 

But it is not only the variety of the lesions of the Irani which may. 
after an injurv. produce Jacksonian epilepsy, that is worthy of careful 
m.t.': it 's tlieir nature which makes the majority of cases recurrent 
utt. r any o]).Mation. liowe- er skilfully performed. At first sight ha'mor- 
rhaj.'.' aiid cvsts woiilil app.-ar capable of bein^' dealt with by careful 
curetting, di'aina};.', &c. {vidi-stiimi). But -loin.; with tlies.- coarser lesions 
there is almost alwavs present .some meiiiiii.'o-<'nc.'i)lialitis. circum- 
.scribed or diffuse, t'oen,* van Gieson,* Starr {vide .sM/>rn)- the latter 
especially— have shown the frequency of tiie occurrence of adhesions 
b.'tween the pia and the cortex, of a chronic degeneration of the 
pyramidal c(>lls. and of an increase in neuroglia. The bearing of this 
oil excision "f the cortex will be alluded to later ( sec p, 28(1). 

Operation. To begin with, a painful cicatrix ' may be freel> .'X. t -'d. 
This may be ''one with some hope that nothing further in the way of 

> Ilrai'n f^un;.. p. 2.'). ^ Zl,<i/ir-^ I!, ilr. I'lilli. ii. I'liiisiul., 188S, M. ii. s. 107. 

3 ,V, ,r y.,rA' .!/'</. ft'f'T'/, A)ii'i|-.'4. ISitll. 

4 111 on.' i.f Dr. Kclu vi rna s lascs (/..c .sH/,r'( ctt.). c-..ii\ ulounia, \iitigo. v,in- . iirc.l 
liv the riMii.ival of a siiiall liliioma adherent to the frontal pericetaum and hupra-orbitol 
nerve l>r. Starr s opinion, ou the other hand, i» much lo88 favourable : " From my 


operation will be n'^uirfil in inscs when' tin- war is c.instiinils innhfiil. 
tender, or hot; whew it «urrfsiM»iuU to the roiirs.' <•( somr kni.wii 
nerve ; and in any ca«e where the i>rijj!iii»l wound luwrutftl, or lontuwd. 
and slow in hfiilinji. and where there is iiny chance of a Hplinter t*l woikI 

or iiii'tiil iH'iiij; ciiilMMlilcd in tin' senr.' 

If it 1)<' n<r.'ssaiv. iis ii usiiaily is. to remove a crown of lM>ne, an 
iippropiiat." si-niilnnar Hap (s.r p. :»»!») must !»■ ivtU'Hetl. with the iiseptir 
an<l KlIi'T piccautidiis alicatlv jjivi-ii. Ila^niorrlmp' is next aiivst.-d. 
ami the Hap r.'tiact.'ill.v Spciir.T-NV.'lls forct-ps. tli.' |«Mi(iaiiinin luiiii: 
carefully turned off the Inme. and its condition notcil as to tliirkcninj! 
and other evidence of old inflainniation. Tin- 1m. nr Iwinji thoniU|ihIy 
(•xi)<)si'(l. tlif siii;.'tMin nnist he itrcpared for the following conditiotw. 
viz. the lini- of iin i>M fiacfnrf. necrosis (indicnted hy a sinus with 
prominent uranulations). li\ periropliic si'lerosis. depressed frafrments 
of the internal talile. spurs. i<v nodules of hone. .\ny sei|iieslrum will, 
of course, he removed. \u>r deidinj.' \Nitli tlie Ihmh' tlie snrtjeon will 
select out of those metlKHls (h's<ril>e(l at p. ;fl(» the nne with wliieli lie 
is m*wt familiar. In trephining the sur}:eon will use the preciiutions 
V'iven at jt. l'r>'>. remcmlierinj; that here he is csiM-ciully likely to Im> 
dealinf.' with a disc of iMtue of varyinj; density at difTen>nt j>«>intH of its 

cireunTference.- It nnist 1 leviited with particidar canlion. as a 

spicule niav have made its way thn)u<:h the dura mater and hi' pressinj; 
on the brair. or be in close contact with one of the sinuses. 

If the tirst crown show iiotliin){ abnormal, a probe sliouM be fzently 
inserted between the l)one and dura mater and carefully swejit arouml. 
.so as to i/wi' information of the condition of t!\e inner surface of the 
surronndin<; bone. If the crown sh(»w chanjies which are. however, 
not localised to it. more bone must be taken away, by one of the metluMls 
described at p. .\[-2. till all that is thickene.l and capable of cxertin>; 
pressure on the brain and its membranes is remoM'tl. 

If ii change can be found in the crown lemoved. or in the sur- 
rounding bone, what more should l)c dime on this occasion '. It there 
be reason to suspect the pn'sence of an e.vcess of cerebro-spinal tluid 
or of an ab-sces-s in the brain, because the symptoms of this conditicm 
(pp. I'l'ilt and ."i.'iL') are present, or because the ilura mater bulgra up 
without pulsation into the t rephine-hole. the trcitmeiit slioidd be as 
directed at |). ■■>■"•). 

Directions as to dealinji with any (>ysts. and how far it is wisejji 
go in attacking the thickened membranes have been <:iven at [). 27.». 
These details of the operation would not be complete without some 
reference to the (jiDslioii of t-rrisiiKj jiortioiis of I In' rnHejr irhrre no IcKim 
sH/flrlcnt to iirfoiiiil for the rjiiliiisii liiis hrni foinid )ii'irc sii jiirfiriiilUi. 
This is not to be lightly undertaken. Professor Nancrede. of .Michigan.^ 
has with great candour recorded three cases in which he took this step ; 

experiencp I connider th»t tnio reflex epilepsy from scant in tho scalp in a very rare 
(Kciirrcncc." . , . ■ 

' Dr. .inlirisdii ('7i«. Snf. Trnnn., vol. vi. p. :i.">) riTiirilx a case where triamiH. fiK ml 
nciiriilL'ia. luid panilvsis. with a rcciirrcnoe of epilepsy (the patient, aiteil 44. hail lM>eii free 
frimi lit.- for twelve 'vear<). were eaii-ed l)y a sharp. aiiL-ular pieee i.f Hint cl in ,i 
painful cieatrix nf the ehi'ek. the lenioval nf whii h was fdlliiwil l,y eoinplele n r..\ery. 

- Free anil must einharrassinL hii'iniMrha'.'e may he met with in sawiie.' tliniii;;!! allereil 
dipliie tiaverseil hy lar>;e sinie Mke vein. lis ehain Is. leipiirin;.' lirm pressiiie .hiriii« ami 
alter the iiperatnm. pliiLjii;- with a tiny sieriii .il w.imleii pe^;. <.i iiiisiiiiiif the hiino 
together with fnreeps at the hieeiling-point. 

' .Inn. ofSiiry., 1S!M). vol. ii, p. 122. 


in all tlio fits rocurroil. tl ugh in om vam not for two and » half X*"** 
wliil«' in nnotli.T " mnu-w .it ov.t three veiint " had plawwd. And thli 
nin.l.iiir in the j.'ieater. a- i'lofes-sor Nancieth- allows that fi.rnierh; ho 
thouuht well ..I thlM pro. ,.<lure. Dr.Sai liH and Dr. Cerster' have >{1vimi 
this a full trial, having' einployt'd it in five <aHe«. Their ex|).-rience 
Irada them to tho coiicliuuon that, in epilepsy of lon^t Btundmg, the 
oxcision of cortical tiisiw doea no good, and Huth e.xt i«i(>n w hereafter 
to I.e restricted to epileiwies of short duration. And again : Since 
Mi. h eortical lesions are often of a microscopical character, excttMm 
should he practised even if the tissue appears to he perfectly normal 
at th.' time of operation ; but the greatest caution should be exercised 
to make sure that the proiier area ia removed." 

Not only imy thia *tep cause severe ha-morrhage. sluK-k, and open 
the door to infection, but is imponnble to see how it can do otherwise 
than leail to fusing of the scalp membranes and cortex in • which 
will become increasinpiv dense with time, and brinj^ about " anchoring 
of the brain." with its f.Mave disadvantap's {s,r p. '2Hi) und Bclerosis 
of the cortex, leading inevitablv to a recurrence of the trouble. To 
put it briellv, -t seems certain that when takin).' this step the sui Ji'on 
is almost sure to replace one tmunmtie epik'iwj' by ttiu>ther, winch, 
supervening somewhat later, is traumatic also, but in addition, unhappily, 
Burgical as well.* , . , . . i. i 

What i.s needed is to prevent the adhesion of brain, membranes, ana 
scalp, and at jjreseiit none of the methods are reliable. Possibly trana- 
planting a flap of scalp, bone, and mend)rane might succeed, but such 
a step is too severe to undertakt-n at the dose of an operation already 
severe and prolonged, . 'id if deferred for some days its object wouki 
probably be d- featw?. The use of g«)ld and other pliable metal plates 
between the dura and the skull will not prevent the formation of adhesions 
between the dura and the brain. A case of Dr. Oerster's proves thib. 
Having removed a cerebral cvst. this surgeon placed a gold plate bet^reen 
the dura and the skull. Two years ami nine months after the first 
operation it was necessary to perform a second, and. while the gold 
plate was found lying exactiv as it had been introduced, the best result 
attained was "that the surrounding tissue had undergone fewer 
changes than would have been the case if the ordinary scar had formed. 
Other materials have been suggested by the ingenuity of American 

Another objection to the removal of motor centres (except, of course, 
in cases where they are involved by a growth) is that this step may 
merely replace one inconvenience by another. It is true that in most 
cases the loss of power has been temporary, but in some this has not 
been the case. Certainly not every patient would choose to lose his 

* Loe. supra eit. . , , ... , , i- 

« After mere incinion of the dura or nioninpe«, tho ncatri.x lift will no doubt, lie linear 
and small, and the inner siirfaee .if the skull smooth and adhcsiiin« ulisent. Imt tho 
rondillon iirosoiit after removal of one or more centres will !«• very ditterent. 

Ilea, h has use<l (.'old foil. Al.lie ruliher ti;<suc ; Imt these Bulwtanies have been proveil 
to ha' disadvantu 'OS of < ausiny formation of adhcsionf and gear tissue, of dUintegra- 
tiiiK oi eausinK su|i|)nration. J)r. 1.. Freeman, of Denver {Ann. Surg. Oet<ilx-r 1898). 
haviiiK tried g^-foil in a case of trephining; for eerelK-llar tumour, and found, three 
mmthn later, that •■ cnimidrrabte new eonneetivo tis«U"> had foruu'd." reeommeuds the 
use of egg-membrane, as being incxiH iisive, rea.lily obtainable, strong in swte of its 
thinness, and duiablo. Mid not, in tho full sense of the word, » foie^ body. The above 
claims are baaed opon two experiments on animals. 


epilepHV ut the v,>M ..f huvinn a ri«lif arm or |MTnmnpn»ly pn; j - . 

FortWm.m'. it U eawy t.. mi.l.TstMii.l tliat iii inr.Ni»ri.ii. • 

permaitent ihimge may Ik- r.sulily ii.tli.t.-.l ..n the .•.•i.Uts , 

tlie motor » - a. " by which oim lorm 

of dbtww I nw ly be exchuniSftl f<>r iiiiotli. r. 

ff it Im? .lM-i<» .. owinji to the Rriivity uiul friMim niy »( thi- utta« k» 
r«iM-. iiillv wli.T.> thi- (-..mlitioii amounts t.» the i«tieut being pnictK-ttlly 
in what i-t a status .-pih-i.ticus th.-ir limitnt-Mi to one or two centra, 
the al.s..iic.> of nnv oth.T ...vtia (civl)ral . us... au.l ix rhaps nls.. the 
failure of u im-vii-us oiHTHtioii. to r.-movi- oil- of tin- motor cfntrfs, 
this BhouM be aiTumtelv l.M.«iis,Ml l.y eh'<tri.ity. To trust to mrasur.- 
ments of the skull » not enough. Sufficient of tl.o motor ar.a hav.i.n 
been exp<«.Hl. the .Itirtt-arachnoid is openetl aiul aH h. inorrhap^ w 
Mnvstcil liv m.aiis of two aaeptic pUitinum electrode*. diUereut partij 
of th.- luotor ar. a an- . xamincd, the results most carefully not|>d, and 
wh.Mi that spot is rcaihed which cuus.-s luotioii m that parfuular part 
of the l) first alT.-ct.-.l th.- tit. tliat \y. tit ular spot, uiu that only, 
ahoukl be ."•.xclHca (K.-n). ■ li<"il'* l">vi' .l..tciiuin.;.i. any ar>.'o 

veins which enter the UcKl oi opration ur. st ti.a with iiu- st. rih/.-.l 
catsiut passed under them by 8ir V. He ..oy s n. r,lU.-du.rtor. Ilie 
urea of til.- c'utr.- is tii.-n ma l;..' .mt by a sharp knife held vertically 
to tii.> surfa. c- vnd i«-n.-tiatii.t,' to .'he white matter. The centre » then 
,.v( is.-.l l)v a sharp " m„ • ..i mms.s. ; . p.itiii t.) th.- same depth, about 
three millinietivs. or u ■; rter ol uu a h. Ha-morrha-e is arrested 
liirature of any bleedinR-pcuiiti it |.os,Hibl.-. h-.t as.-pti.> lotions. .,r 
compreaaion with gauze wrung out of hot lotion, or st.-rilis.-.l naliu 
chloride. The cauterv should never be resorted to if it can possibly 
1).- avoi.l.-.l It iiitr.xluces sepsis and suppuration, and iiiay U-ad to a 
h-rnia c.-r.-bri. It prevents the surgeon bringing together the Haps 
of dura mat.-r ..v. r t lu- .-x. ised centre. Drainage will uauaUy be requiretl 
on acouiit of th.^ .).)ziii<;. , ■ i i 

Aft.-r the removal of the centre, to make sun- that this iia.s heen 
effectual, it will be well to again make us.- of t!..- .-l.-. tii.' t. st I K.-eii). 

The strictest a.septic precautions should be tak. ii b. l.n.- ami duriiii; 
th.' operation ; siiHici.-iit drainage should be provided and. in bringing 
th.- \v.)un.l to>;-th.r, th.- .Iraiiin e-tnbe must not be pressed upon or (!rea» Can- must lie ta.^.-ii to k.-ep tli.- w.ain.l sterile later on. 
infection lea.liiif: to inf.-.tiv.- s.)ftenin^' and hernia ..f th.- brain. Only 
if it has been m-.-dful t.> remove niiieh bone should any .)t this be 
preserved and replaced, with the precautions given at p. 

In cases where during the operation there has b.'.-n any .-s.ap.- of 
cerebro-spinal fluid, the dressings wiU soon need to be repacked or 

Causes of faUure after tre^iiniaf l« trasauttie cj^^. These may 

be summed up as follows : 

> Prof. K..clu,r. of H..r„ ( Sent. M.d.. April 12. 1S!I!.. ].. 121). is ,jf opini..,, tint M,.t 
only should tlu- 1...110 ili>. r...t l.o rrpl.ic. il. l.iit tli:it th<- nii.t. r its. lf Ur « i.l. ly 
BXClwjd. H.- holds i„w of th.- .-hi I aiisi s of , i..„ |..-y . oMM-tH m an , xa^r^...ii.t„,„ 
local or geii. ial, ..f th,. int.a.-.unial ,.ivs.u,... Ho h. li. v. s timt M. a m.mb.-r of . of 
exciiion of c n l.,.! . . ot„ ~. , x. . ,.1 m. th..>o wh,-,.' th,- ,;xi-,s,on ha« b«*n Hufhcicntly com- 
Xto to hri,,.. .ihoMt a delinit.' ,untlvsis. th.- su... ss .houl.l bo attribntr. rafh.-r to tho 
opening of the <l..ra mater, which establishes « gort of safety- valv siisc. ptil.^ of r,.g.ilut.ns 

' Kli-h^i wou^iTheiirfore, only put back the di»o where a very definite teion. such as an 
exortoo. or growtli,h«ibe«> removed; ia«Uoth«»the»kull»fcouWbeleltopeii. 


(1) Not hiUing off the right sjwt. A bony spicule, uiul.'tocte.l at tlio 
operation, has bwn found, at the necropsy, not far from tiu' trcpliinc- 
holc. To iiu'.'t tliis (•()iitinj:<'iu-v. or to find a clot, it has been advised 
to swoop a pvnln' or win' loop carefully round the vicinity of the trephine- 

(jpt'iiiiig. . . . 

(2) A jicnoral and dilYusf tliickcniii}; of the bone round the site ot nijury. 
(IJ) .Mend)ranes too niucii thickened and too adherent to the cortex 

to admit of their being safely detached. , , • • ■ 

(4) Owing to the hmg continuance or to the ainonnt of the irritatmn. 
tlu- i)rain niav be ])ernian.Mitlv affected. Thus, in Dr. Uunn's words 
already .pioted («< p. -J.")!)), there are cases of depressed fracture in 
which" "the (oiislaiit irritation lias liej^otten i- permanent ini])ression 
upim the brain aiul nervous .system which remains after the olTen(lm<; 
point of bone has been removed." The f;ros.Her and more locali.sed 
the lesion the more speedy will be the relief. As long as the bt« "re 
diminished in number an<l severity, the prognosis is still hopeful. The 
fits iiiav !)(' verv slow in disa])pearing. 

(."n \Vlii!e marked relief has b.'en jziven in some cases of violent 
temper, delusions, and melaiuliolia. whether associated or not with 
h)cal epilepsv. the same rule holds with the former as with the latter, 
i.e. if the interval between the injury and trephining has been a long 
one. the cure is verv lik<dy to be imperfect. 

Hi) Xiyh rl of iijli r-trrotmeiit. IxAh medical ami sniylnil. but chiefly 
the fiiniwr. I'liilessor N'ancrede's words' are worthy of remembrance: 
'• Tlie r)peration. in.lci'd. removes the most important cause of the 
epilepsy, but oidy one cause. The disturbed circulation in the nervous 
centres, and the excessive mobility of the neivous svstem. can only 
disappear with time; and if all other soiuves of peri|)lieral irritation 
are not most carefully guarded against, the jiatient may be slightly, 
if at all. benefited, whereas judicious after-treatment wdl .sometimes 
relieve an ajiitareiit o])erative failure." Judicious after-treatment 
shoulil especiailv refer to alcohol, exposure to the sun, overheated small 
rooms, and. lienCrally speakiiii:. the jiatient sliould lead a healthy life. 

(7) Tit iihiiiimi for jits imt hi loiiiiiiiij l<> tnniiiiatic I'ltilciixi/ iii rliiiniclcr. 
There is no (hiubt that the glaincmr of a new operation and ' the chance 
of finding something"' have led to this operation l)eiii>; iierformed in 
unsuitable cases, which have not been published. It cannot be too 
stronjilv laid down that no operati<m is justifiable in other epilepsies 
save the .lack.sonian. of which so many are traumatic in origin. That 
is to sav. that in ordinary idiopathic epilejisy the conditions justiiymg 
operation be of the very rarest. They would he something of this 
kind : Epilepsy with intense local headache ; ei)ilepsy in which, after 
the general cjinvulsions. paralysis or paresis of any grt)up of muscles 
follows. Those who trephine an idiopathic epilepsy because it is 
ini]iossil>le alwavs to exclude traumatism in idio])athic cases, or because 
there is a bare |)os.sil)ilitv that a hainorrhage. the origin of irritation, 
may be met with on the surface of the brain, are likely to meet with 

(«) An infected condition of the W(mnd. almost invariably occurring 
during the operation. an»l bringing about («) meningitis; (b) hernia 
cerebri ; (c) cerebral abscess. 

(9) Shock. 

' liihr. Eiir.Siiry.. vol. v, |i. 10L>. 


Fiiiallv ill rasos of Imiu st doubt, and in those whoro a wpll-ronsi.lpnHl 
operation' has fail.'.l. the intcif..,..,,.-.- of the sm;.'.-.,,, will h'' ]«8t«h«l 
bv the fact that tiauiuatie epih' teii(l« to tirow \vors.>. aii.l is little 
aileftea by in.-.lieal tivatinent. In the words <.l Ivhevenia. one- 
declared, traumatic epilepsy, due to injury to the iiead. leads to early 
insanity or to feebleness of intellect. 


ruder the above headilifj such bodies as bullets, knife-poiiits. iV-e.. 
are included. Depressed and i.solated fragments of bone may come 
within the meaning of foreifrn iMnlies. but have bten considered 

(«fc 1). -■>Z . Ill 

A. Ihillih. ■I he followinu <|uestioiis will su<i}! themselves when 

a surireoii is callfd to a case ol bidlct wound of the skull : 
( f) lias llw hullrl jK iii lriili il llw sk ull iif till 

(2) // iiini/ Iwrr i,iiss,<lli,t>r<T,i thr Imtw <uiil Ihr ihun iiioUr. inlhoul 
penettatm/ the latter, and remhed a simt qxile <>,it y^jhl- I'lol.ably m 
most hands a second applicaticm of the trephine, il at some 
dista.Kv from the wound, so as to extract the bullet th.-re would he 
preferable to attempts at removin<; it from the orifimal wcmncl. 

(.•!) //f(.s' llu hall spill into liro „r ,i,u,r pinrs ( Halls elonj.'ated as well 
as round are liable to s])lit wIi.mi iinpinv'in- on sharp an^jles of bone 
Thus when til.- ball splits upon the ..iiter table. jMit may pass beneath 
the scalp, while the rest may drive on before it soni." j-l the internal 
table, causiiif; pressure on the dura mater, or even reach the brain. 

(4 1 lias the ballet imiefrated thr hraiii '. If so. where does it lie > 

(.-)) (hu/lil lui'i t.ii>l,>rotm\ to lir iinjianied at one - and if so. how far 
is the sui'fieon to jin ^ , .,, 

If th.' last .lue.stion be answiTcd in the ailirmative. an answer will 
be "iven to most of the others. . . 

While, owing to the rarity of f;unshot injuries of the head m civil 
practice in this country, it is verv diliicult to give a dogmatic answer, 
the followini; reasons are in favour of .'.xploriiig in all cases in which 
it is clear that the iiijurv is not goin<; to be (|uiekly fatal : 

[a) The fact that oiilv bv e.\ploiin-: will the surj.'.'..n be able to answer 
the (iiie.stion c.'itaiii to i)e put to him by the friends, whether the brain 

is injured or no , . • i . 1 1 ■ 

(6) Whether the bullet has split, wla-ther the internal table is 

shattered and. if so, how far it resembles a punctured* fracture, are 

points which alone can be cleared up by trephining. 

(e) Disinfection of the wound and good drainage are almost hopeless 

unless this be opened up and e.\pl(.iv<l by trephining if needful. 

The following case is not onlv a good instance of the kind of gunshot 

iiijurv to the 11(^(1 which may be met with in civil piactic. but it shows 

how slight may be the injury which actually originates the fatal 

mischief. It was brought before the Clinical Society * by Mr. Lucas : 

The patient, aged 21. had shot Imii-. lf with a small rcvdivor. • Almost in the 
rontre of Ills forehead wore two small < ir,-,ilar holrs. «ith slightly,l rdtJ.s. 
The suiToiimlinc skin was rnlsd into a roinidrd (.mmmriKc. 1 lu iv was .some 
bleeding from the none as well as from the wouiuls. On turning luiek ilai.», a 
' Lor. s«pra cit., p. 277. ' Tm«t., voL xii. p. 5. 


l.kckrncl cavitv waH oiK'uod l«n.ath tho nkin. fonned by the expaiwion of the 
S'^afterif ^ the iut. gu.ncnt. At the bottom o( th« cavity, a 

ir.ewL t ru if , rm aperture wa. seen in the bom-, a.ul lymg ui-<m the ...ternal 
able w^re t^^ tlattencfd bullet.. The internal table was dnven '-'-^ ^j'-; 
the appearance of a wnu8. in which the bullets were lying V. Vl h 

we were under the improsMon that the man had very huge frontal su us s M 
^ Wn owned by the bullets. After removing nnraerouii fragments belonging 
Sh^xte^STabl^ and diplcn^^. the splintered internal table forming the posterior 

**™:':ira^^";i:tr^aie.lp.d. angular fragments, tw.. of which wj^ 
grooved l,t™L ir.gitu linalsi,u.s. \V1^^ the internal table had been removed the 
d^iTt ma Jr was seen at tho bottom of the woun.l an.l pul. ,.iug. The membrane 
ts e "reex'U at one s,k,.. where there was a -rli'^r^'"",^'' Brftr"?Ctt.Llli 
nn.le bv stabb nc the T'oint of a penknife into a sheet of i>aper. But for that small 
m. cture it is i„u^ th'at he woukl have recovereT Infective 
Eon in about forty-cight hours, foUowed by death early on the s.xth day. 

If tl.e sur.'.on decides to explore the wound he does so with the 
i„t..nti..n of ivii.leiinj: tlie wound as sterile as possible, removing all dirt, 
hair, an.l s,,li.,te.-,s in the cortex, if accessil.le. without inak.nfj the condition 
of the patient worse than it is. He will have warned the fnends 
that removal of the buUet may he foun.l iin,.ra( ticaMe on tins occasion 
owing to the mtienfa condition. We will suppose that no ccrel.ral 
svnnVtonis are present, either focal urn's to tiui.le hi.n. m- mu i tr.ave ones 
a"s coma, sfrtor. ,)aralvsis of the sphincters, which w.mld lead hiiu to stay 
his han.l. Lastlv. the injury is not of that destnictive character .so 
shattering the skull and pioughin!.' up the l.rain. especially in a direction 
towards the ha.sal j;ani.'lia. as is certain to prove .|iiickly latal. 

Localisation. This can be accurately a.scertame.l by radiographic 
examination. Surgeon-General Stevens.)n' thus sums u. the question 
of localisation : 

It is not the bullet so mu, h as the frMgin, .ts ''''■'' /'•J^' -VT, ^lll'^*!"! 
eause inf...-.ion. This i> bnriw out by the military . xperunee m ^ou^h .\fnca. Her. 
also while suppuration was rare after bullet injuries. ,t was I"'*- *^ 
fragments of Hull. •All expl.,ringinstruiia lUs. ele.trica and other, for the M^^^^^^^^^ 
of lodged missiles may nowa.lays be s. t asi,!.- as out of date, and de,K.nde.. e placed 
, reU- on the u>e of X-rays for this purpose. By tli, ir ...cans, iising MaekeiY- e 
DayidM-n s . ross-thread localisiT. the exact iKW.t.on of any foreign IhuIv th 
tissue can be ascertained to a millimetre, or sterto»scoi.ic photographs may be tak.ii 
whi. h will afford means of sufficiently e.xa. t estimation of the poMtion ; 
as large as a bullet to warrant the surgeon in o,H.ra ing f.u- it.s '' "'"^'^ ' 
more accurate localisation. When using Ihts method, s.uall pieces 
be fastened on to the skin above and below the bullet, so that its ^' 'j^'^; l ^ 
to known points on the skin may be shown m t le st. re.iseope. ' " ^ 

indication obtained for the o,K-ratiye procedure to l,e carried out. i;'"^ ' « 

to localise the bullet, or to skiagraph it stereoseop.eal ly. Its general posit u n should 
be a.Mcrtain.d by means of the lluoreseent screen or by a single skiagraph m. that 
mrt of the limb or b.«ly in whi. li it is situated may 1«. plaee.l m he proiK-r lK>«.t.on 
oyer the photographic plate while th.'.se methods are Ijeing earned out. 

.Mr V W. H. Sla'utoii. Surgical Radiographer to CUiy s Hospital. Wlfes as 
follow.s : ■ It is po>sible by means of the Rontgen Rays to estimate the s.ze of and 
to e xactly locate bullets .'.r other bodies which have iK-come odged in the 
. avity. The simpl. st method, IK-rhaiis. is that^wherc two radiograms air taken-- 
<me iii an antero-po.sterior direction, and the other in tin- lateral. Anothe. >>>tem. 
and a far more accurate one. is that now in common use at (.uy s Ho>pi ai. it is 
a system whereby the exact distance from any giye.i ,Km.t may be 
principle uiK,n which it is has..! as follows : When an imag,. is b. mg vie ve.l . n-n 
the scrwn and thi- IuIk- moved, the shadows of the vat .ous ,,arts of th.. obj. ct 
viewed »-ill move uiion th.- scnn-n at different raters a. < or.ling t.. '''' '^^d';'';;"" 
the screen ; that is. the nearer to the scr.'.n the less their slia.lows will travel .n a 
• Rtport on Smgient Cau* noted in ike South Africa n War. 


al all. l!v a ,n. oxact nuwur.>mHil« an- . umK ..l.t,.in..l 



■ al a . !v a s>ii alili- niiciiaiiisiii . aw i ■-• . 

,. i a ,s..s\,h. .v .1... f.-n iK,. l..«ly can b.- m-t-n u,>on tho ; , , 

,,;„,,,lislu..l witlmut t!«. .-m,.l«y.n.-nt »f any ..hotograph.c ;''"- ;r-,,, , , V^;,,' . 

Xained. ra.liogra,.hy .an .... f,nH,. r. ^ "^.^^ Z 

adviMti for ca«eH of bnlk-t in tlu' tu iul. 

Thou-h probes n-.t I..- us.'.l f..r l..calisi„)i tlu- position of tho 
bull SeJit i. vcrv sup.Tti. i.llv s,tua,..l. th.v ..v of us. ,n uI.m, , v.n^ 
it when its position has b.M-n .l..t,.r„Mn... by .;i ra,l...,'rapl,... ♦ ; 

Sonio, blunt^stmment slu.ul.l bo ...nploy.-.l. s.ul. as N.-laton .s. «l.uh 
is provided with a rouiuled porcelain knob at its ext . 

Treatment. This .nav be .onsi.lere.l under two hembngs. (') "'t 
opening up of the ^voun.l for the purpose o removn.R J'-agnu-nts of 
£e and bruis.-.l tissues, an.l f..r d..aninf: the w..und and provuhnp 
drLasre. (2) The removal of the bullet. 'Yin. may biVir"-* 
K S wUl depend on the condition of the patient and the situation 

^ho^Swing remarks by Mr. U. H. Makins- are of twofold interest^ 
first from their reeeur .late .nnd their bearing on the etlec of modern 
smdl projectiles ..f high velocity and, secondly, from the wide practical 
experience and weight with which the writer speaks. 

"Ooerative interference is iiocessarv ii. evry cas.< in wl.i. h ry is j...lK.>.l 

the frontal r..Rion, arc seLlon, s,.ital,l.. f...' ^r ':'^]"'^""'' .^^^^^^^ 
,>f ..n »v.,il • l,„tinall..ll..Tsai. .■ al.'.l. 1 .is.> the word exptora 
of no a%ail , . t ' j ,1 f , „,„.rati..i. of trephining w seldom nect*- 

t,on. '''"^'V . of it from a very 

K;a;;?.:nh:VraU ott.r.:th^^^ ma^tg sueh enlarg..ment 

of the bono oiw iiinc as is necessary with Hoffmann 8 forceps. 

T » scX s .oul.1 be first shaved and eleanse.1 ; if for any n-ason .... at.... 
U i,. ^l^'^hlrp^ceduro at least shonld bo oa.^^! o.... with a vu^ o.|...n 
as far as possible, 'future asepsis infect,.,.. ... head "'J' " ^ ' 

A^^^r ♦/» hn foared Tho sea P l.av.l.i; b. . .. cli ano.l "ith aU lalt . a ...i). i> la. i. 
iX^tte bXt"opi^.inB f.,!>ns tho'....,,-,.! ,,oi,.,. ,.,.,1 .ho w..u,.,l ox, ,,._o,.. In 
riilt^MeTthe entry wouu.l is Ih.^ <-...■ of .hi. i ....|.o.ta,..c;. a...l tl... .M ...ay 1..^ 

« Surgical ExpcrkHO-^ w,A%,„(/, l/nV. Ih-J!. liHM). 
both extoiisivo and sevens 


great a distance as two inches or more from the surfaoc. The cavity innst be 
thoroughly explored and all splinters remov.-il. 1 hnv se.^n .nor.' thai, t.fty . x- 
tracte.1 in one case of oin-n pitter fra.'t.ire. The l.rai.. pulp a.i.l cl..t nhr,..!,! th.M. 1.. 
aentlv removed or wawhca awav. a.i.l the »()i...d closed without dramaKc h ras 
ment'-i of Imne, as a .-ui.-. arc l..'ttcr not replaced, but compl. le suture of the skin tlap 
is alwavs advisable in view of tlie great importance of pi nnary .iiimii. ami the tact 
that a drainage oin iiing exists at the original wound of e.itry. and that the wountl is 
n'adilv reoiM-ncd to its whole extent, should suc^. a step become dtwraWe. 

• The .Icteclion of is most .satisfactorily done with the hnfter. ana in 
all but simple punctures the opening should be largo enough to allow thoro.ighl.v 
elfeetivc digitid exploratio.i. The determination of the amount of bran, pulp wl.i<-li 
should be removed is somewhat more diffieult : all that washes away readily should 
be removed, and its place is usually taken up by blood. 

" Few fractures of the base arc suitable. f..r operative trcatm.'nt : the only o.ies 
I saw wcrw those of direct fractu.cs of the inof of the orbit or nose, produce.l .y 
bullets passing across the orbits. Here the advisability oi mtcrfermg with the 
injured eve led to o|M iiing of the orbit, and someliincs exposed llie frielure. 

'• As to tlic most sati>faet..rvtiiiiefor the pcifoiinaiiccof theseoiKralioiis . . . m 
head injuries the advantages of carlv interfeieiice were moiv evident than m any 
otlicr rei'ion. This d. pendcd ..n the fad that, as in civil |aact ice. the scalp is one of 
the most dangerous ivgions as far as the auto-infecti.m ot the wou.ld is concerm-d. and 
one of the most dilh. ult to cleanse except by thorough shaving. With regard to 
the treatment of retained bullets which are stated to have U>en distinct y rare. 
Mr. Makins a.lviscs that the oiK-ration should not lie undertaken until the 
patient can be place<l under the best conditions which can Im> secure. . . . . >wA\ 
operations need the infliction of an additional wound, require great <lelieacy. an< 
may be very prolonged in jH-rformancc." Eariier interference is only 
where the bullet has tried to escape or seeomlary symptoms develop pointing to 
irritat ion. 

Operation. A. Ih,- jiositioH oj tlir hiilhl Ims ,i«t Imn (hUrmiwd. 
either m acenunt of the condition oj the iKitinit <>r Ihr rndloiimithic i jowi- 
imliiiii miiij liiire Ixrii ineonclmive. While the lieail is beiiif? shaved 
iiii.l pivpaiations for the operation made, the siirfreon vs-ill take note 
of aiiv .sii].erli( ial lesions, a:-; bla'-keiiiiij; of the .skill. Imn.iiif.'. the 
presence of jjiains of powder, and thi' orij;iiial i liaraeteis of the e.xtenial 
wound, both for medico-legal and for future friiidanc.-. all 
these lesions being soon liable to alteration. It is laiv. siippo.smj; the 
patient to have recovered consciousness, that any localiisnt; .symptoms 
are pr(>sent. which can )ioiiit to the lodgment of the bullet in a detiiute 
part of the cortex. < .</. the motor or the speech area.' In a few cases, 
as soon as the whole head is shaved, the surgeon may gam evidence 
of the position of the bullet by finding on the opposite side of the skull 
a contihsion of the .scalp, an "elevation of the bone, or even a tender 
spot, beneath which, after incision, some line hssures may be detected 
(I'helps).- The surgeon, having raised an appropriate flap, enlarges 
the wound in the skull with Holfmann's forceps and removes any dirt, 
soft parts wiiich will ceitainlv die. and superficially lying splinters. 
In order thoioughlv to lemove'anv powder, dirt, or lead spla.shes from 
the external wound in the skull, even after this has been enlarged with 
Hoffmann's or other forceps (see p. :U2), it may be needful to resort 
to rubbing with sterilised gauze, or even to use the gotige. The wotmd 
in the dura should be sufficiently enlarged to give e.xit to any blood 
or cerebral debris. If uninjured, or very slightly injured, the bullet 
having been dellected, the dura should be most carefully examined 

» Any sudi icsions, «liit li luav be ii.ile.t linn,, .ii.itely. arc due tw Cm- j,:i-.-:»j,'C of the 
bullet : "if occurring later on they will i.iarlc certain seco.idary inorbid c<..i<htums. 

a .V,, -Trftuniatto Injuries of the Brata and its Membranes." by Dr. Phelps, of New 
York. p. 343. 


before it is taken for grante.! that the partH ben-ath l.a^v .u.t Won 
i.nnlicatcl. If this ....Mnhrane. though umnjuroC .ul- . s 
a ways to h.- ...mmmmI, K.a;;in-..t8 of bone act-essible NV.thn. tl..- .-...f x 
loid at. th - . mul In,; 1..-.. ' .'.mI. sought for with a prol.e 
or even w th h. tin;:er an.l. wh.-n I- 1. .v.noxv.Uvith .Iressn.g forceps 
o^a si oop. fh. ballot n.av .lisrov.-nMl m th- .onrso of th.-so 
Z^^us L. unless it is soon mot with, .ts -tn.H.on shouM 
bo postponed to a future o;H'ration whon its .-xa. t j-uMt. on has I. n 
J c. lists Tho oponing in tf.o .lura should be suthe.ont v 
exit to anv l.loo I or corol.ral debris. If irngation of tho b, llot-tra. k 
is^ nr. 01 sod with tho viow of ron.ovin.' infeete. dots or sloughs, it 
wil be ivl to ph.,' round tho oponin, i.. tho skull with stnps of g.u.ze 

2 X.^uid oalry^nfootod partil los tl - ^ ^ 

simces Dr. Phelps is ..f opinion that d.ama-o ti.l.os aio to .o omplo>u 
ZlZnX reserv^ and only in oasos wW.o tho.o .s ,r...t -ulvs^oad 
,h.n.a.'.' to tho .ontial regions of the brain. If used at all .Lamag. - 
t'ibos shi.i.ld bo withdrawn and abandoned at a very early perHnl. 

"^tu; f::ih::;;::::;:i.:i;ons to t. n.piov.,.o..t of dndnage tub.. 

be remeinborod : (1) That thrv an- untant tco.,-.. bo.ho^. (-) 
thev Lre likely to become tilled with dot. and tlu.s act as plugs rathe 
tSS. ?as drainl Ci) That they are media f..r tho doop .mplautat.on of 
infectivo oloinoiits wl.on the surface is no longer storilo. 

If tho s....'oon fails to find the bullet he will, in the map.ntv ul . asos 
ao ve to «;it tor an improved condition of his patient and careful 
;ji.'ti;.,. 1.V tho of 'tho Ur,nt,on ravs. If « X^ilt 
must considor whothor tho stato ot tho pat.on jnst.hos t^er "ittr 
ference. While profound uncons.'.onsnoss aiul' .oina >i 
marked condition of shm^k contra-indi.ato a..y I''''":;''^-'''" ';};;' ; 
it will 1.0 hotter if the site of the bullet is known with auxthn., i. 
cer to ron.ovo it at once, and so mininnzo as n.nch as poss.ble 
ihe ist of i..foot,o„. Bofu.o i..llicti,.<: this additional mjur>- and 
rS n.^^^g tho risk of causing, perhaps, further severe lo«« 
incisio,^ in scalp, dura n.ater. and bran,, tho s.,rgoon w.ll ' • ' "^'j' 
take into careful consideration tho con. .t.on a..d vitahty .. h,s jm u 

B. The removal of the hnlh t. Whoth..r this is .h....> at " « 

as tho cleaning of the wound or hiter. when the condition of ^lie 1'. h it 
has in.nn.vod it mav be effected through the original woui d or bv 
CO into 1- rophi. in.', tlo' advisability of the latter oFration will depnd 
u n , p o io-fof tho bnllot. Tho conrse of the projectile withm the 
skull is of!o.. ,o.,v erratic, as it n.av ho doiloofd by 
either with the dura, or with bony pronn.ionco. A ; ' !^ 
oxamination mav therefore show it to bo m an ea.silv ' \^ 

at some distance from the wound of entry. It will now bo n^^^'f^^y 
to CM d,.r those cases where, after careful exploration, the patient has 
oe. aved from tho risks of inf.. tion. but though the bullet has not 
been found tho w..,i...l has hoalod. Tho M"-t,on then arises as to 
whether the bulU^t shonhl be romovod or aihnvod o u na n Where 
leadachc or any sympt.nns aro ,„osont. w.- w.ll ^> 
months after the injury, the co.irso to . .How _,s ' r^"- , 7'* " 'J 

radio.rvapl.ic exa,ni.,atio„ clearly l.K;ahses the bullet. Hut it is not 
so ea'sy to give an answer in those cases where ^^t?' 
wound! cerebral BymptomB are absent, or extremely slight, and pechap. 


the Rr.ntfjon rays are unable clearly to define the position of the bullet. 
On tiie ()iu> hand, anv honest surgeon knows that by operating he may, 
ill spite of all Ills ca'ir. expos.- his pati.Mit to danj^ra weater perhaps 
than those eiitaile.l hv I.'avinfi tiie l.ullet alone. On the other hand, 
the evidence is .strong; that if a larjre iiuiii1).t of cases of recovery without 
removal of the bullet were accurately watch.'d for lonj; periods, many 
would be found to be cases of incomplete recovery. . • ■ , • 

The evil results of allowing a foreign botly to remain in the brain 
are usually manifested sooner or later, even as long as fifteen years 
after the injurv. Intlammation. slow or rapid, sometimes mvolvmg 
large porcions of the brain tissu.-. or yellow softeninf.'. is apt to be set 
up around the fon"i<:n sul)stan(e. eitlier spontaneously, or rom the 
most trivial .-.xcitin"; caus.-s. The usual termination is cerebral abscess, 
this condition having.' been found in fifty-three cases m winch a necropsy 
was performtHl. Apoplexy is an occasional cause of death, as is pressure 
of the foreign bodv on the venous tnink.s, inducing ventncular ethision 
and conse.ment compression of the cranial nerves. The probable 
e.xi)laiuition of tliose cas.-s in which no .symptoms have been present 
for long periods, but in whicli <leath lias rapidly upon the 
sudden development of brain svmptoms. is that .(uoted bv W harton 
from Flourens. This observer found that bullets introduced into 
different portions of the uppr parts of the liemisi)heres and the cere- 
bellum graduallv penetrated the brain substance, ultmiately reaching 
the basi.^ era. ii. the bullet tracks healing after them. " There is probably 
no autluMiticatea case of recent An^do- American record in which a 
bullet left in the brain substance has failed to work mischief, nor has 
the mischief be.Mi oft.'u lont; procrastinated. Tiiere have been occasional 
instances in which it has remained harmless for a number of vear.s in 
the cranial cavity, but the brain has not been penetrated, llie tact 
that epilepsv has developed so late as fifteen years after injury must 
make even apparentlv . xcptional cases doubtful."' 

Tiie following d. t ailed bv Mr. W. Sheen, of Cardiff,* which w 
an instance of removal of the bullet by c()unter-trephining at a second 
operation, will be found extremely instructive : 

The patient, a iiiau a t. 23, had been struck by a revolvei buUet about 2 cm. to 
the left of tlie mid-frontal line, and the same distame above the Bupra-orbital arcli 
OwinK to the depth of the bullet, about 12 cm. from the point of entram o. it was not 
considered advisable to extract it at first. Ten weeks later there were ..till attacks 
of left parietal and frontal headache some motor aphasia, and in the rigiit 
ten. The position had iK-en localis<d with the l{..ntg.a r.'iys by Or. Martin. 
,^ose remarks are quofd billow, at a depth of ti-.-. cm. from the lateral surfa.o o 
the head. \ Hap was turned down behind the left ear. and a one-mch disc removed 
above ami behiml the meatus. Thi.s opening was enlarg.'d downwards and for- 
wards, the dura mater op. ned. and the bull. t s.a.elie<l for •■ by entering a 
probe :!•.-. em. above the m.atus. and 2-.-. em. behind the intermcatal "ne, and 
liassing it in the horizontal plane of the head to a depth of tWj cm. /he bttltet not 
.eine felt. Medley s telephone probe was passed in the same line, and after leelll^ 
.1 moment a rather doubtful tap was felt. The probe was withdrawn, and a pair 
of ordinary di. ssinR forceps passed in felt the bullet, which bobbed about m an 
elusive waV, suggesting the possibility of its being in a cavity. At 
attempt the bullet was removed, with a httle brain .substance adheiinp. 1 lie lengt h 
of forceps introduced measured 6-5 cm. from the skull surface. As there was con- 
siderabte increase of intracranial tension, some of the bram substance liad to bo 
removed before the dura could be closed. The disc of bone was replaced and the 

« •• Traumatic 1 iijuries of the Brain and ita Membraiios." 
2 Lancet, vol. ii, 11)04, p. 82j. 


ir"ve*SX"Hfttr.ft\:;".Ho! patient «.«med w»rk «. a .toUer. 

and » believed to Iwive Li.iititiur<l It .siiu f. 

S^^' nent l^^-lack.. pain on nu.ving the head an.l at Last o-u- ^"v... 
L t uk f h.M,.. with fMuporar; remission of svmptonw 1 h-n m 
n is..s I. t th.. iM-avv hull-t nu.y rhan^- its pos.tu.n ; . s bom, l-lt 

i ■ ..t tl„'. (.Deration supports tins possibility. 

" Th"r;;;:.l of t W Ma^h! on thl'result of 'the radiographic 
exami!»ation arc of eipial intcrost : 

,,.,„„. „l ita bull* in .n.l ; ; , , „„ ,.„|:,, hi,,B .tv|, 

so difficult to cstiinatc. 

\ nunib.T ..f intov stin;. cases of bullot wounds of the skull an. 
.eo^Jl^. Suj..on.. 

,Xr ol,s..rv.tion aft.-r the operation ,s deeuledly short. Ih." bulla 
appears to have been in a very inaeressible position. 

Six day* after tc,n,>-r.tun. rose am » ; „ ,,.,„.. p,,„oved : 

unaccountable forh.s ..f.-ns Next >,;'',; , ,j,n,,t.,M.s again 

dura found Werat.^l ; drame I. ' " , , u.^ier 8cal,. atove mhi ear 

appeared and he «f «|'';' ' • g f,^ a here, from abscess i„ the 

li. Other foreign bodies besides bullets which may penetrate the 


l„,,i„ aiv k,>if<-}x>i»tH. These, with their teiMleiuy to form .■.•n-l.ial 
al.s< rss. liavr all.-ailv Ix-on «llmli>d to. , , »i 

(• \m,ih, f riaxs uf fon-ij:,. Ixxlv whifh may be met with by the 
»ui-.'on in civil piuHiir is sliowii in the foHowiii),' caw' of Mr. Cmipru: 

on iU n iJof a., iron ,.,.lisu.lo. Whm l..o,.L'ht ,„to hns,„t;.l l.- rr yx a ■ l.-anr it 
w«md tW q«»rtorH '{ un inol. l.m« nmn...lU., l.v ..u.l. r tl... .v- . ar partly 
ovTr?ai. "a bv it- lolmlr. I., tl.i- tl„. . n,! of a la,.-.. .......h - of ...wal. . onr. 

to to mma.!dH, inwanls an.l a lltll. forwanis fn.n. tl... out. r wonn. , wlu.l. was 

iuuatt7ri?«n h,ch uml. r tl... . xt. rnal .n. atns 1h .^ n tl,.. n,,.l ,mK-e«« ami 

h. r tl" ja« . 'rh..r.. was .on..; l.l.-.Un, fro.n th- '^^^^'l,;:"*;!^'^^^ 

mr iKwIs Tl... I-ati.nt was put un.l. r . hLo-oform, ami Mr. ( ou|«T iUWH-rted. 
' ft r n .1. O.V l.l.. wr..n. l.inl'. in . xtra. ti,.i: tl..' iron. I)»nn« thrHe ertortK 

; Vtl,, i .... was o,.t. but a sniall .,nanlity of «..,n- luul .ram snl-stanc 

T...' K Hi^l.t fa.ial i»iraly»i» came on two .lays aft.r tl,.- .njj.ry. th.-n 

1 h , r tUs' tess. an.l on tl,/ nevnth .lay Mt l,. n.i,.l.«.a follow.. I by . ..n- 
vul si ,ttX a Uing the riRht limbs a...l tl... ri(jl.t half of tl... fa.-... I wo .lav . 
. T «; , acoi;i..nt. II... ,,ati..nt .li.-.l. At tl... n-. ro,.sy . 1,.; .u^l^rr 

of tC riZ Lxm>\n'r.' Hl..m...I w.-ll-niark,.! s,.b-ara,l,n..„l ' 
««terior «'rto^ mi.l.ll...-. r. b,al 1..1..- ha.l b-..,. .l, - |;ly w.M.n.l.d : I,.. 1,. a m 

SXltS't tin. n sof,..n...i a,..i stn-ak,-,! w,ti. ,.„s. - i^" 

snike had enteppd ju«t ni.,l..r tl„. ap..x .-f tl... n,ast<.i.l p.-on-s. t.ay.s .1 tl.. int. mat 
X a.u" dH"m^H.v,..-al b-nrwlar ..,l,ss..s of ,«.t..,us bo,..-^h tl... dura mat.T. 

It, a similar cas.- tin' .av.-ful use ..f <'r would hmon the 

f„n.i.n, l,' ..ixMrn.!: of tin- xvouinl nv.,u1.1 fanlitaf .Irainavre 
and deansing the parts danmged. indudin^' tlu- l.nm. it-s -lf ami its 

» London Hospifil n^portx. vol. u ; llHtehm»0H's CliHicl S„nl., vol. i. p. 'Jl. |>l 




Motor Area. The motor an-a. or that part of th.' forfx i" ;vl.ul. 
l,.sions .aiLs.. paralvsis .m th.- opposif si.U- of the JmhIv. Iu-s lMM..;alli tlu- 
anfrmr half of tho pari-tal i.o,,.. If is situ.n ! '"'7''<!'"t^\'»J""^^^ 
of thr tissur.. of Kolan.lo, oc upvin^ th- prrc.-Mt ral .•ony..Iii ion. Formorlv 
it was thou.'ht that tho MM.K.r ar.>a ..xt.-ixl.Ml l..'hiii.l tli.- hssmv r, 
Kolando into the post-central convolution. It is nuw rcco-n.snl that 
the latter eonvolntion is c(»ncern."il with muscular ami tactile s. nsr. 

Six akin.' sii.Tinctlv, but pt-rhaiw with sufficient accuracy for pnu tual 
„unM.s,.s imralvsis or .•onvulsions limited to one lower e.vtremity mean 
{hat tlu- l.'siun is situafd in tlu- upiHT of the motor area 
and will call for ivmoval of l.onc in this situati.m : paraly.sis of the arm 
,M,ints to a lesion in the middl.' third of tlic area : while paralysis ol li.> 
face indicates a lesion of the lower third. The centre lor speeeh lies .m 
the left side) a little below and in front of the latter area ami is situate, in 
th.- first frontal convolution. Where lesions are combined a more or less 
extensive removal of bone over the corre.siM.ndinft areas will I.e ealled tor^ 
It will he seen that a simple method of markin},' out the hssure ot 
Kolan.lo is of «reat importance to the siii-eoii. This may be fairly 
accuratelv niarke.l out as follows : Draw a line between the root of the 
m»se (nasion) and the external occipital protul.eraiu'e (imon) :;ct this 
Hne and take a point half an inch behind its centre. 1 his w.ll fine the 
upper extremitv of the fis.sure, i.e. where it meets the nies.a! '...i-itiulinal 
fissure of the brain. From this a line, four inches m en^t li is .Irawn 
.h.wnwards an.l forwards an an-le of ti7-.^." with the first line. 
This allele, which is three .piarters of a rif,'ht angle, is easily measured. 
The second line indicates the fissure of Rolando, so that the motor area is 

just in front of it. , , , „ 

SirR. Godlee, in the classical case mentioned on p. J'.U used the tollow- 

in- simple method of marking out this fissure. A very similar nu^tlio.! 

was emploved by Mr. Makins and the late Mr. Anderson. 

(1) A line was drawn between the nasion and the imonas described 

"'^"(l') At a ri^'ht anjilo to this a secon<l line was drawn vertically down- 
wartL throudahe front of the external aii(lit()ry iiit-atus. 

(3) Parallel to the last another liiu- was drawn vertically upwards 
at the l.'vel of the posterior Iwrder of the mastoid process, rea.-liiiig the 
first or loii-'itudinal line (1) about two inches behind the .second 

(i) From t he juuet iun of lines 1 -a'.-A 3, one was drawn diagonally down- 
wards, reaching the second about two inches above the external auditory 
meatus. This corresponds to the direction of the fissure of Rolamlo. 



Withrppiiiil ti.iill sill flic 
here he pMiitcl oiil tliiit lli 


nmikinipof thecrn.bwU^iwoluti""'* it i''"> 
,,im...»c«i ana miturwi of tW skull, an.l tli.| 
rt'lationt* of the uulti ana 
ciitivoliitioim beneath to 
till' <riiiiiiil siiifiicc are 
liiilili' to viiiiatioiis. 

Position ot the chief 
ratnrM (Kin- Tlu- 
mninal siituri'. tlu" aii- 
tci ior limit of the parietal 
lioiif. niiiythtw be traced. 
Tlic iM'iiit wliiTi' it leaves 
the Ha;.'ittal suture, the 
liifj!iiia, may In- foiiiul l>y 
ilruwiiii; a lint- fi<>m a 
point just ill front of the 
external uuilitorv meatus 
straight upwards to the 
vertex; fr»)ni this point 
the coronal suture runs 
downwards and forwards, 
spaking niuglily, to the 
middle of the zygomatic 
arch, or more exactly, to 
join the temporal part of 
- the great wing of the 
sphenoid, which it meets 
an iiicli and a half above 
the miihlle of the zygoma, 
and not ((uiteaii iiu ii lif- 
hind the e.vteriiul ungulur 
process of the frontal 

I'lider this suture lie 
tlie jiosterior extremities 
of the three frontal con- 
volutions for the frontal 
IoIh' lies not only under 
the fnmtal bone, but ex- 
tends backwards under 
the anterior part of the 
parietal, the fissure, of 
Rolando, which forms the 
anterior boundary of the 
frontal lobe, lying from 
one and a half to two 
inc lies behind the coronal 


The occipito-parietal 
or lambiloid suture, the 

\-\,.. iL'.t 
to Mirfacc 

1. The iiasiiiii. 

A. Sliottini; ti latiuii^ i>f rhicf wfflirnl suli-i 
ill -Uiill. It. Slidwiiifj ehii'f sulci ami their 
ivlatioii- 1(1 siirfucf of heftd. 

i. riie iilion. 3. Mid \><>ini 
betwwn nasion ami inion. 4. Fissure of Kolando. 
5. SillK-rinr temiK)ral crest. II. Inferior teiniM.ral 
crest. 7. Svlviati point. S. !1. 10. 'the Ihiie imil.s 
of tlw Sylvian li«siiiv. II. 'I lic iwrictal . niin.'iiie. 
12 Th.-'iimUi tuUnle. 1.1. The lamlxla, 14. 
Klist tenipofo sphenoidal sulcus. 15. hxtcrnal 
larieto - .«•. ipital sulcus. 1«. L.-«oral sinus. 
17. U'vv\ of the base of the cerebrum. 18. Ex- 
ternal auditory meatus. 1». Rcid'» base line. 

posterior limit of the parietal bone, will be marked out ' 

Starts two an.l a half inches above the external P^^'P't"^ Pf?*f a 

and runs forwards and downwards to its ternunation, i»hich in on a 

(iHOWTlIS Ol" Till. HllAlN -'»> 

Ifv.'l will) th.- /.vfioiiiii. iin iii. li iiii.l 11 'nuirt.'r li.'liiii<l th.' nwaUm. .U 
t\u' occipital lii»M- is ii.>t ill.' lH.ili"n..f tl..' .M.ii.ital 

iHiii.'. but cxti'iiiU ( iiii.l. r ...v.t ..f tlw i part ..I lli.- 

|Mtri«>tal, th.> tissm.' Ii.'s al...iit ilii.v..|uait. is ..I an m. h 
m fnmt of the bih.x of tlu- laiulHloi«l sulure. Hut tins van.s a «.»..! 
.WI ncronliiiK to th.MmHifiratioii of the tnbnlar part of th.' «Mi ii»ital. 

Til.' s.iuamouH suture is not casv to iiwrk out, owing to the irn'Kularity 
of its curv.'. Its liij.'li.-st is usually an inrh aiitl thn-e-qiwrteni 

above the zv j;iiMi«. • 1 1 I 1 

The Sylviau Hssurc. which sciwratcs th.- t.'inp.ii..-spli.'iioi<lMl IoIm- 
from the pBriftal, pass.'s«|Uely upwanls aii.l a. 1..^-* this 
suture near it* niulille. the teniiM»ro.»i»heuimlal I«.1m' lyinn iM iu-ath the 
h>wer part of the iMrietal as well as Hwler th«? i«huium>u« and the gn-at 
wiuL' of the sphen..iil. /. 1 « ^ t 11 

To mark out th.- tissure of Svlvius it is neeos«ary to hud first ol nil 
the Svlvian, which r.'pr.'sents th.' sit.- ..f .liwr^.'nc.' ..f the three 
liuilwof the tissure. This jHiiut is situat.-.l an inch ami a .|uarfer lM-hMnl 
the external angular pn»ce«iof the frontal ami an iii. li ami a half alx.v.' 
the zyfioma. " The luain poHterior horizontal limb of the Sylvian lissure 
passes backwards and upwartls from this point to a p»»int situiite.1 three 
tiuarters of an ineh below the nuist prominent jiart of the parietal l»tuie. 
'1 11.' vertii al limb is dirwtwl upwanb* f«>r about tlirw-quarters of an ineh. 
whilst th.' anterior horia>ntttl limb passes forwards for about the same 

' The following practical ixuntsare given by Pr«»f. Nancrede. foHowing 
M. Lucaa-Chainpionnicre.* 

(1) M(Mioplegia. or siwsnis limite.l to on.- limb, or a [K)rti'>n of one 
limb, in.licat.' limited lesions. If the lower limb be atfecte.l le umHT 
portion of th.' ascending parietal convoluti»in (Ki;.'. l2f)isinvol\. .1. iJone 
must th.'r.'forc !»' rcimfvccl ov.t the iippi-r part .>f the motor area. 

(2) With paralvsi.-i .if the arm an.l I.-;.', the h'sioii prolialily involves the 
upper two-thirds of the area with possibly the parac.'iitral lobul.' on the 
mesial aspect of the hemisphere. The trephine should thus be placed 
at the upper part of the area, and the opening enlarge«l upwards or down- 
wards as re.juired. 

(:$) Paralysis of the upper extremity ahme pr(»bably indirates a 
l.'si.m at the mi.l.Ue tliir.l ' 'iscemliii-: frontal convolution, and the 
trephim- shoiil.l be ajipli " in front ..f th.' mi.hlle third of tlie 

fissure of Kolando. 

(4) Paralysis of the l.iw. .• part of the lace iM)ints to a lesion in the 
lower third of the motor a I. a. 

(.")) In simple aphasia a disc of bone should Ije removed lower down still, 
in front of and below the lower extremity of the ; it fissure of Rolando. 

(()) In most cases inore than one cntre is atTect.'.l. and conse<|Uently 
a considerable extent of bone may reipiire rcin.ival. Lesions which 
irritate a localised area of the cortex, r.ij. a spicule of bone, a meninj;eal 
htemorrhage. a localised meningitis, or a firowth. produce spasms m the 
corresponding groups of muscles on the opposite side of the body which 
are supplied by the cortical centres irritated (Jacksonian epilepsy). The 
irriti'tion mav involve adjacent centres, causing widespread and even 
geneial convulsions. Lesions wlii. li .Ic-^Hoy any area of tlie iyrU-K pro- 
duce paralysis on the opposite side of the body corresptmding to the 

» Rawlings, " Surfaco SUrkii^*." ' liUern. Enxyd. Surg., vd. v, p. 90. 


nf till, firnt tcnil«>r«-sl'lH'ii<)i<lal convoltttWli. Licsioiui unr , 

1 I I " " ♦h.. .u ti.Mit btniiB unable to underatond ■puki'i. »<)rcU. 
" w«ird deafiH-iw, the iMitu-iit ujhik ... __:»tL. wordii are 

The vwnal apeech or word-Bceing centre, by which written wonw -re 

r,., ,24. Outor mnlMCC ot b«h.. riK,wfag locJh.tfc« «rf eWrf o«eb»rf e«tfrc. 

n„„n-< iated li.'s in tbe angular f-vnw at a point higher up and behind the 

AU the alH ve are situat.-d on the left side in rifiht-haiided patients. 

The cortS centres f..r visi.-n lie near the fissure on the 
inner as^ec of the .K-cipital lobes, below the level o the paneto.occ.j.ita 
Cure (E rJ4). Each is a half-vision centre and receives hbres o m 

tlu san e sTde of each retina. Lesions of «n^"'»tr^ P^^"^*'. 

to the tosion. 



A few instances will be given under the following headings : (a) 

^""i;1vX. K/Sr r2).,«o.. an, Treatn^nt of L,.^io 
the Head (F..r examples see also pp. 301-308.) A typical case ,n wh ch 

a:i\^^^ =::i^:tx;;;;;a!;:^ 

o^t^'S^lylu be the result of later inflamnu^tory 
'^"nSi'cas.Championniere • gives this interesting case : 

1 Lo TripatuUion ffuidte par lu Localinatioiu urthrak», p. 107. 



front ">f th<' Hfnlp wrniml. . „ • 

...,.1 ,«.in i.. 1 1.'; l. ft t l.r I,.-,.. 

Inil n.. mnilvMHiT l..>s of s. ti>ai m.ii. Ahmm»H 
w ar «aM foim.l ..v. r \hv l- ft .''"!»'• 
two in. l..s from ll..^ .M.-rwil awglj" h<- 

•/.vuoiiM. Hot li 'of'"" •>* "phi"!" ("•«>«« 
Hi nnorv wor.l-l.lilKllM'*') »'•'•»• »" "« ■■"•«'»••» 
t,.„t lirm-iit. Kiv.-* I «" > "'<' 
cxirforwl, »n«l a woun.l of tli.' s.|uainon« Ih.ii.', 
inWttn.1 Hh.M«"liMv to hav 1.- -> i>... 
duc«l I.V a Hmall )- nUn. .•. fo.i.Hl a h1 . mI 
out in a trrphiru- 'I hr kml.^ Im.l jk m.- 

triit.-d til.' <lii!a an.l Inaiii.tli.' 1 ni;.' i-.-l. ih.i 
l.ran. ho( tlir mi.l'H"' ii.« iiinu-^'l ' 
Th<^ .luM oiM M.-d. a Minis foir.'iw was 

Kr.itlv nasHnlalouKlli'- '>'■"" 
M iMialmi! th.-' I.loo.! .I'.l 1"''^<'"»«'<1. 
an'l was ura.lually . A.ri.d.d l.y l-r"'" P"*- 
siirr More clot was tht-n watihed away l>y 
,1 Htrtam of weak iHrhloride lotion. A 
drainage-tMlw waH in-.-. . ' On tho . v. ninR 
of the Mme dav the aphasia wan inurh ini- 
proved. Next morning tlu- JMlti.-nt was aKan, mo,v apl.ash . 
{to tube had be«.me hl.K-k.-<l. On fr...-,n« ; ' 

SVyWkill tuns Jul ,>robat.lyinjur.^ . „ 

(b) Cerebral Localisation inthe Dia.jHosinand «< «<«™/o/( '.r..*.yA>. 
Th ollowin.' cas... tr.M.lmu.l by Sir K. Gmlloe for Dr. Hn^ m ^ l?..,„ 
in 884 » is ..f .Tcat partly bfcause it was one of ti.e .as... 

o removal of a Uii.iour fro.u t ho brain in this country, a.ul alno on account 
of the ^mpletene^ the details and tlu- accuracy of Ins n-as..,nn.. 

& m« «»ed twentv-fiVP. lia.l four vears U'forr sutT. n'.l from slight .•on. ussion 
f™ia MoVT^tKt s ,f tl... l«.a.l. A v-ar lat. r tluM-- lirs. .... ,n t«,.. lHnt!s 
^Tito le Hw^*? tirmoutl. an.l tongue. ,,aro.xy>n,al and n r. gular m ...•.■urr..n.-.-. 
S^me mLl^ a ter tits began, with loss of ,o„s. ionsnc ss an-U- m ral ...n vulsm. s. 
Some moninn aiur ■■ ^ , , ^.,,,„.^ . .,n.l six months In^fore a<lmis«i<m, 
TW. eonditton his « , " ,v weakness of the left filMp-rn. h.».«l 

twitching, of the left a . , ,,revent«l hin »mxg his 

iU^^of"ho Wt'ingers. tlnnuh an.l han.l. the eltow movements were very 
1 rn„v«!-i..n- in .h,.n,s..lve. an- only an m.licati.,.. for interference when they are 

,„caiis;d a;::i -t. a..,. ...p-iaiiy .f ''n/r^''?;:!: J tr^Si^ " 

* Sir C B. Ball, Trails. Hoy. AruJ. of Med., Irelano, voi. vi, p. ioj. 
» Med. Chit. Trant., vol. Uviii, p. 244. 

ami it «as fonnil that 
with liiiiki ii-.lowil .'lot 
ivi red nninlerru|>t.dly. 


limitcl. those of the sli(»il<l.r iiii|>aiiv(l. Tliiiv was no rigidity or wasting of 
nnisi l. s. Tlu- td. s of the Iffi l. g .liil not ( l.^ai- tlic H'onml in walking. Tliere was 
|M i>isl. nt v<.Miitinn and ictcliiij^:. with attac'kH of lancinating heiMliu-he. rendering 
life inlolt ialiU'. l.iiinc iloscs of t lie iodides were fruitlefK. 

\n oiK iatioii iM-ing dc< i«U-<l on, the motor area and the Jitwnre of Holando wciv 
niaiuKcl out. Thforotiiiillv. in onler to hit the middle of the «Rsurf .if liolando. 
the centre of the trephine »hould have Un-n aliout half an inch iK lnnd the 
diagonal line and about an inch and a half from t lu' median lonniliulmal line. As. 
however, there was a tender s|«it on the seal]) two indies anterior to this, the lirst 
trephine oiiening wa« made Ix-tween the two. The <liiia mater was normal : after 
a cnicial incision was made in it. the hiain was thought to lailne idinoniiatlx . and 
to lie rather more veMow than usual. .\ se.ondilise was r. inoved with the trephine. 
oveilai.piiiK the lirst. external to and sliylitly in front of it. and the ,mi;Ies of lioiie 
werei imiidedoll withapnifje. Thoelwo opeiiiiiKs were then joined l.y one iKisterior 
to them so that an ainrture measuring two inches liy an inch and tlirce-iiuartcrs 
»as made. The dma mater was opened anil a surface of lirain exjiose*! nearly 
e.iual ill si/e to that of the skull oiK'niiiH. Dccupyini! most of this Njmce and croiwmg 
it ohliuucK from alxive and Itehind, downwttrd« and forwards, was a convolution, 
into the ccnirc of which an incision was niotle. From an eighth to a ipiarter of nil 
inch Mow the surface lay a tran»l>arent. lobuliited, solid tiiiiiour, thinly cneaiisuled 
but quite isolatetl from the surrounding brnin substance. The ineisioii into the 
cortex being prolonged, the sides of the growth were easily separated hy a sti^el 
siiatula. The 8Ui>erlieial surface .of the growth lieiiin thus isolated, tins portion 
was removed with the linger. As part now iiroUe away, the deeper part was 
enucleated with a sliarii sikkiu. the .scraping Ix-iiig eoiitinucd till apparently only 
hcidthv hrain matter remained. The cavity, aliout the sr/e of a pigeons egg, 
lille<l up with blood, aii.l spon>;e pressure failing, the ha iiiorrhage was eventually 
cheeked liv the electro caiileiv. A drainage tube was inserted iK'iicatli the dura 
mater, which cls.'wlicre «as <li Awn together by sutun-s. The skin wound was flosctl 
anil an antiseptic dressing applied. , , , , i 

The wounil was not tlrcssed till the third cky, when the scalp near the wtiund 
.■,1-s somewhat o clematous. The ne.vt day wet lioracic dressings were aiiplicd. but 
a hernia cerebri as large as half an orange was jirotrudiiig through the lips of the 
wound. There were no twitchings of limlw or face, no headache. I he patient was 
bright and cheerful, with a gooti apiietite. The hernia c. iel.i i. however, iiicicased, 
and on the eighth dav. having reached the si/.e of half a cm ket ball, was siiip|HM 
away with scissors, the parts removed consisting cliiclly of ^'lamilar ir:atlei ami 
clot, witli, apparentlv. little true ccri'bial stiiutiirc. 'Vht- hernia ccn bri a^iin 
increased somewhat, but all s.emed to be doing well. when, on the twenty-tust day, 
a rigor occurred, headache and vomitiiij; followed, then rc^stlessmess, sleeplessness, 
and gradual sinking about four weeks after the operation. 

At the autopsv cxli iisive .uachiiilis was found. The parietal area ajiju-aretl to 
have fallen in : ii'i its ceiilie. and oceiipyiiig the imsition of the fissure of Holando, 
was the wound in the liiaiii. The destn'u tioii of the cerebral cortex involve<l nearly 
all the aseeiidiiig parietal i onvolin ion. the iip|H'r part of the ascending frontal, and 
the autt rior third of the supramarginal gyiiis. The extent of softening was not 
great, but it was dinicull to tell this accurately, as the brain had undergone the 
process of hardening. The growth was a gliiiina, of the size of a walnut. 

Ill the cmuiiiciitu oil tlif ciise. iiuiist iiitcf<'stiii<; iviiiarks are {.'loiipcd 
under tlic full.iwiiif; lieads: (I) (liii^'imsis. (li) .siiii.'i(iil ticatineiit. clini- 
cal jihciKiiiu'iia after the (>])eiatioii. (1) ivvcliitioiis (if the 
phv.sidlofiicallv and patholofiically coiisiilcreil. 

These will repay most careful perusal ; only the chief points can be 

ijiven here. i ■ l ■ 

( I ) Diagnosis. A brain tfi.iwth on the ri^rht side was diagnosed in this 

case (in ttie l(>ll(i\viii<; l'iouikIs : .shiw pioirress. uncontrollable voinitinft, 

vidlciit ]iaiiis. (Idiiblc optic neuritis. 

It was tiioiiuiit to occupy the corte.x because certain motor tracts 

were iniplicat('(l in detinitc order, |iaialysi.s wa.s present witliout 

loss of sensibility, and alM)ve all because of certain iwroxysiual seizures 

of liK-al convulsions occurring without loss of consciousness, eniiiientiy 

suggestive of irritation of the grey matter. 


In this CHS.. Oiore was tM,.ni.U-t,. paralvsis ,.f ll.;' lin- rs a.wl lian.l. with 
,„„|,l..t,- ,l,„,cti„n ..1 tho n...t..r "f / 7 ■ ' • 

,:;"x;:'S."''S'"1.s;':;e ly ^-^.^ 

to be immediately under the surla.e, a.ul ro.ui.l.'t. 1> m.noIm..^ 
the entire thickness of the cortex. ■ u ♦ .. ...^t tlw In nior- 

It n.av be ,| whether it was a.lvisal.l. t.. a n.M 
rJl mm the ..te.i..r ..f the wound by means ol the i^.'lv'""-' .\- ' 
" n' was nut severe and would no dord.t have ^"7''- "^^^ 

I •. m l n,."ans The use of this instrument apiM-ars t.. have brnu«ht 

Vn,rcS;sTnX^^ "1 tlu. tun,our. C.nunh.nt also th. 

m B«Telations o! the Necropsy. The brain was. practically ev..rv. 
whe^?] h^Jtt e'ejt over the a'rea injure^l by the operation am -n he 

. It uoi .hown «t the ,«. r..l«y if th. UU ral ha.l U ' U 


iiicnibianos in the iiiinii'diatc iicifiliboiirliood. Tlio inciiiiifjitis was due 
to irritating matter fti)ni the interior of tlie wouiul flowing <lownwar(is 
between the layers of the arachnoid, and aenmnilating at the base of the 
brain. The local ; ilainniation of the wound had opened out the parts, 
and separated the adhesions so as to allow the dischar;^ to make its 
way i!ito the cranial cavity, but not till three weeks after the ojK'ration. 

The following case, cjuoted from a paper by Dr. Kisien Russel. read 
before the British ]\Iedical .\s.sociation in ]!H»7.' is an example of a case in 
which the position of the tumour could he ascertained with practical 
certainty, and in which it was successfully removed by operation. 

M. H., a wniniin ngeil 40, ('oni]iliiin(Hl of incrcnsiiig weakneiw of the right foot of 
two months' duration. Hho next noticed twitchingM of the right toes in attacks 
whieh lasted for a minute or two and which occurred once or twice in the twenty- 
four hiuiis. Thcsi' clonic movements and the motor weakness jirndiialiy iisccnded 
the hnili. until six weeks after the commencement of her ilhiess they cnlininatcd 
in a .laiksoniMii lit, wliicli, cominencini; in tlie fnot. Kulpse(|ucn11y involved the 
right arm anil face, without loss of ( onscionsncss. A similar lit occurrcil three 
(lays later. Seven wec'ks from tlie onset of tfie illness she liesjan to notice )irofjrcssive 
loss of |H)\vei' in the right u|i|M'r lin\l>. She hail liceii eiitiri'ly free fniiri heailaciie, 
anil .it no time iliil she Ijcconie aphasie. When she came nniler olisei vat ion there 
was herni|i;iresis of the right side : the face was only slightly alVerteil. the arm nuieh 
more so, and the leg most of all. Indeed, no movement of the ankle or tiM'S wa.s 
{Kimible. A diagnosis of a tumour in tlie leg area of the left motor region was made. 
Sir Victor Horsley ojicrated, with the result that a tuntour the size of a walnut 
was removwi from alwut half an inch liencath the cortex of the leg area. As an 
immediate effect of the ojieration there was marked of the hemiplegia, but 
the paralysis suhsequently imjirovcd so that before the patient left the hospital, 
seven weeks after hiT o|H'ration, feeble movements could 1h' made in the right 
toes and at the ankle, in which parts no movements had been possible before the 



The chief of these are : (.\) The existence of a growth ; The 
site of the growth : ((') The depth of the growth ; (1)) Is it single or 
multiple? (E) Its nature : (K) The conditions which justify operative 
interference and the probable results of this stej). 

Tiie above points, and the five first es])ecially. nuist be decided with the 
help of a physician ; and it is to be hoped that in future physicians will 
invoke, at least, the opinion of the surgeon at an early stage of the disease. 
In too many of cerebral growth the operation has only been resorted 
to as a forlorn hope, a fact which is always to be consideied when the 
mortality from operation in these cases is estimateil. Inlm inatioii with 
regard to (]Uestions(A) to (1)) will be obtained by referring to some .standard 
work on medicine. The stirgical aspect and treatment of these cases 
necessitate the discussion here of questions (£) and (F) at some length. 

(E) The nstare of th« growth. Before dealing with growths of the 
bpHin itself it w ill be necessary to allude to those springing from the dura 
mater {.sec also p. 24.")). 

I'rof. Keen - j)ul)lished a case of tlhroma weighing over three ounces, attached to 
the dura mater, which he removed successfully in a patient aged 27 in 1887. The 
growth dated probably from an injury in ehiMhood. It caused epilepsy, aphasia, 

> Sec Brit. Med. Jonm., 10O7, vol. ii, p. 1123. This |nper and the discuttsio" - hich 
followed contain much useful information as to the localisation of cerebral tumours, and of 
its practiral value as resanls otierative treatment. 

* Amer. Journ. Med. Sci., 1888. 


coiinili-tc li( tiii|ilc)jia. iiitenBe neuralgia. cIcnfiH'nn. i\n«l gn-iit imiiiiinncTit of \\>\im. 
Afl< r tlir oixTiition. («ive for the eye hikI syiti|il"iii-'. tli<' olli. is li .<l |m-sr.l 
away . xcciit Hlowness of R)M>ei'h ami the fpileiwy. aiid tlw last h.i> mhii Ii iiii|iiom iI- 
111 the Niime iteruKlieal for IS'.Mi (vol. . xii. p. ."-(i:!). I'lof. K. c ii yiv. > iIm- >lati' of tins 
mtient nine years afler the (.|K iatioii : •■ i:v. >i)j:lit still iii'in i f,ct , I .jiilcpl if.a iii 
attacks ic iir" MOW at intervals <,f al>oiil a year. I'ali.'iil still vc iy iinvoiis aiitl 
nnalilc to ilo any work." 

Sir W. Maiowcii' lias piililisliiil a c.isi- in wliii li a urowlli of llf <l>'ia in, iter 
caused inilalivc lesions of tin- Idl frontal lol.c. The i>alii iit was rcslnre<l to jierfeet 
health after the o|K'nition. anil ilieil i ii;lit ye ns later of I'.rinlit s ilisi ase. 

Ill the above-mentioned ciise the omwtli wiis limited to tin- <liiva. A 
detailed account of a case in \vlii<li a ^jrowtli oiifjiiuitinf; in the dura 
involved the cortex of the brain ii* recordeil by Dr. Hrenier ami Dr. 
Carson, of .St. l./oui8.* 

The gn)wlh was an enilothelioina. OwinK to tin- eli.n.icleristie spieail of the 
lianilynis from one, the shoulder centre, to the others of the iip|N r i \l lennly. the of ({rowtli in the liraiii was made. tlioiiL'h head e li.'. vi rti<;o. nausea and 
optic neuritis wcrr- aliseiil. .\t the o|K-ratioii alaiiiiiiiL' h em. >ri liaise look place 
durin); the removal of the hone uwiiiii to the iiiiiiieii~e >i/e ot some luaiiehes of 
the |K)stcrior meiiinmal vein. This was c lieekeil l.y paekinv' while the oiH'nint; wiw 
enlaified. The diiia was dark, l oveii"'' >. 'tli lai>;e vessels, and did not pnlsate. 
It wa^s adheicnt to a >;rowtli liene.itli. w! ;. ■.. though friahle. was easily lifted from 
its ImmI hetweeii the dura and the apparently lie.ilthy hrain. The patient ili<Kl on 
the twelfth day with pyiexia and delirium. At the necropsy a jHirtion of tlw 
growth was found to have escaped removal, and the niicroseojK- showed that the 
surface of the liiaili was itself invaded. 

It will now be neces.sary to consider <!i< ' tli.-* of the bi;im itseli. 

Almost every form of neoplasm may 1m* found within tl i .inial cavity. 

The nn)st common forms- are sarcoma, {jlionia, tuberculous tumi>ur, 
syphilitic tunionr. endothelioma, and cysts. Less comnmn are fibmnia 
and osteiinia. while rarer forms are hydatid cysts, psaminoma. Hpoma, 
larije aneurysms of the arteries at the base of the brain, and tumours of 
the pituitarv body. Some helii as to the Viirieties of i.'iiiwfli most likely 
to be met with, and the relative iivi|Ueiiiy of each, will be <;aiiied from 
the followiiif? table.» The interval since the publication of this paper 
may make it appear out of date. Owing to the care with which it was 
drawn up. and the sound i)atli<ilo<;ica1 basis tm which it rests, this is not so- 
The paper remains one of >.'r('at value and is still ijiioted and relied ujxm 
bv different authorities. It will be iiotieed that Dr. \V. Hale White's 
conclusion that 10 per cent, of the cerebral <.'riiwttis ( (iliected bv liiin ( (iiild 
certainlv have been operated (in is distinctly hioher than is shown to 
be the case now in the lifjlit of the e.\iierienee of twenty ye;irs later. 

Of one hundred cases of cerebral growth the projKjrtions were as 
follows : 

Tuberele *^ 

Glioma . . • . -t 

Glio-gareoma ...... 


C'nrrtnoma . . • • . •> 



Cyxt 1 

Gumma ....•••••> 


' Latttrt, August II, ISSS, p. :»1I4. -Im-r. Jniirii. M''l. Sri., lA l.ruary IS'.t.V 

» Dr. W. IWe White, Ouy'a Hospital Report*, 1888. 


Of the forty-five cases of tubercle, the (•richiiiiii was aiTti tcd in twviity- 
two, the cerebellum in twenty cases. '1 lit- firowtli was multiple iit nine- 
teen, anil single in twenty-fi»'ur cases. In all the forty-five cases one or 
more other structures than the brain were affected. Dr. W. Hale White 

coiichulfs that not iiiorc than three tuberculinis cases were \'\ke\y to 
be l)ciie(ite(l l)y oiicratioii. and even in these the other oriran.s were 

Ot the twentv-four of jiiioma. of ten only could it be ,si . i tliat 
thev were not infiltratinj;. TIk- cerebrum was the .seat of the disease in 
thirteen cases, the cerebellum i four. In one case there were multiple 
gliomata in the brain, and in tw ' others there were growths in other iiarts 
of the bod v. . . 

Of tile ten of .saiconiata several atTected the dura mater in inae- 
ces.sible positions: of the five cases which attacked the brain only, one 

alone could have 1 n removed with any prospect of success. (»t the 

remaining growths none of the carcinomata or glio-sarcomata were amen- 
able to treatment. Of the four cases of cyst one could certainly, and 
another pos,sibly, have been operated n\wn ; the myxoma was, and tlie 
lvin])h()iHa was' not. amenable to operation ; and of the three doubtful 
cases, two could have been operated upon. Dr. W. Hale White's summing 

up is as follows : ■" Thus we sci' that out of i himdred cases of tumour 

«)f the brain, ten might certainlv have been operated ui>on. and four 
additional ones might possibly have been ; so that in Id per cent, of our 
cases we can hold out some hope of operative relief to our patients, pro- 
vided that a c(»rrect diagnosis of the position of the growth be made, 
even so late as shortly before their death, whilst, of course, earlier in 
their histories many others mijiht have been operated upon with a good 
prospect of success." 

The following are the conclusions of another physician of great 
clinical and pathological e.vperienie -Dr. Byroin Hramweil, well 
known as an authority on this subject, the conclusions having been 
given at a debate on Intracranial Surgery, at the Medico-Chirurgical 
Society of Kdinburgli." Dr. Hramwell considered that the cases in 
which intracranial tumours ( an be succe.ssfully removed by the surgeon 
are rare, a consideration of the conditions present niakini; it easy to 
understand why this necessarily be the (I) In a certain 
but verv small' number of cases an intracranial tumour is not charac- 
terised by any symptoms <luring life which enable a positive diagnosis 
to be arrived at. CJ) In some of the cases of intracranial tumour in 
whicli the svnii)to;ns c.'i. lieadaclie. vimiiting, gidditiess, and double 
optic neuritis distinctlv show the ])resenee of an intracranial tumour, 
there are no localising symptoms wliieti enable the plivsicinri to 
determine in what part of the cranial cavity the tumour is situated, f hese 
cases constitute a not inconsiderable proportion of the whole. It is by 
no means uncomnum to meet with large tumours in the temptiro-sphenoidal 
and frontal « lobes, the " silent areas " of the brain, which are unattended 

» Tram., vol. xiii. 18!t4. \>. 180. . , , 

» There Is inrn-a-iiiiK cviiU-nw to show th»t the frontal loin's can no longiT U- le^'urdi'd 
a.s " silint anifc* " a.s has hitherto been the taM-. Sir 1). Ferrier (AUbutt anil Kolltston'a 
,s'i/«(< m ../ Midkinr. vol. viii, p. M\) eomex to the following tomlu.«ion» with regard to the 

fiDiilal liiiii. : 

(i) l,c>i(>ii< cif tlic frontal IciIm- ina.v lie Miiil In lint iiili i i|iii-iit ly Intent. 

(ii) (III the lit her liaml. in Mime i'a>es, (">ihi iiilly if the lesidii is liilatiTttI, and even in 
the cast- of l. sjiins which are not cakutateit to cttU!<e prewiurc or iliKturbance of the brain 
in general, there may be mental symptoms of which the chief chartKteristics are failure